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LIVING  ANATOMY 
AND    PATHOLOGY 

THE  DIAGNOSIS  OF  DISEASES 
IN 

EARLY  LIFE 

BY  THE 

ROENTGEN  METHOD 


BY 

THOMAS   MORGAN  ROTCH,  M.D. 

PROFESSOR   OF   PEDIATRICS,   HARVARD   UNIVERSITY 


THREE  HUNDRED  AND   THREE  ILLUSTRATIONS 


PHILADELPHIA  6?  LONDON 

J.   B.   LIPPINCOTT   COMPANY 


CoPYKIOHT,    1910 
Bv    .1.   B.  LiPPINCOIT    CklMl'ANY 


Printed  b>i  J.  B.  lApphicoU  ComjMtny 
The  Washington  .Srjnare  I'mm,  I'hiUideliihia,  I'.S.A. 


TO 
WILLIAM  OSLER,  M.D.,  F.R.S. 

REGIUS  PROFESSOR  OF  MEDICINE,  OXFORD   UNIVERSITY 

IN   RECOGNITION   OF   THE   AID   WHICH 

HE  HAS  GIVEN  TO  THE  DEVELOPMENT 

OF  THE  SUBJECT  OF  PEDIATRICS 


PREFACE 


The  Roentgen  ray  has  been  largely  used  as  an  aid  to  diagnosis 
in  both  early  and  later  Ufe.  Its  mechanism  has  been  fully  explained 
in  various  books,  but  a  systematic  exposition  of  the  practical  results 
of  the  Roentgen  method  of  examination  has  not  yet  appeared. 

The  purpose  of  this  book  is  to  deal  as  little  as  possible  with  the 
questions  of  apparatus  and  technic  and  to  devote  the  entire  space  to 
the  actual  clinical  teaching  of  the  subject. 

This  teaching  is  accomplished  by  means  of  illustrative  plates, 
by  legends  corresponding  to  them,  and  by  a  text  explanatory'  of 
what  can  really  be  seen  in  health  and  in  disease  in  early  life. 

The  book  is  devoted  to  the  diagnosis  of  disease  and  does  not 
deal  to  any  extent  with  treatment.  It  is  intended  to  provide  a 
means  by  which  a  fair  knowledge  of  the  Roentgen  method  can  be 
acquired  by  the  student  when  the  personal  instruction  of  a  skilled 
Roentgenologist  is  not  available. 

I  believe  that  in  teaching  Roentgenology'  it  is  of  the  utmost 
importance  to  present  illustrations  of  evident  conditions  and  not 
to  mislead  the  student  with  vague  descriptions.  In  the  plates  I 
have  been  careful  not  to  allow  any  retouching  whatever,  and  I  have 
discarded  those  which  would  have  to  be  altered  in  order  to  show 
what  would  be  described  in  the  legends.  Unless  this  is  done  the 
plates  are  reduced  to  diagrams  and  lose  their  value  for  accuracy  and 
for  teaching  the  student  to  interpret  them  independently. 

The  plates  are  placed  opposite  to  the  legends,  and  the  illustra- 
tions and  details  are  given  to  the  student  as  would  be  done  if  an 


vi  PREFACE. 

expert  Roentgenologist  were  standing  beside  him  describing  the  plate 
by  means  of  an  illuminator.  The  different  parts  of  the  plate,  whether 
normal  or  abnormal,  are  designated  by  leaders  and  by  letters  just 
as  the  Roentgenologist  would  designate  them  with  his  pointer. 

The  two  methods  are  in  this  way  identical,  excepting  that  the 
questions  which  the  student  may  ask  have  to  be  anticipated  in  the 
legends.  It  is,  therefore,  important  to  make  the  legends  cover  what 
a  fairly  intelligent  student  can  reasonably  be  expected  to  ask.  It 
is  important  to  explain  in  the  text  whether  the  different  parts  of 
the  illustrations  are  normal  or  abnormal.  This  is  not  only  to  antic- 
ipate possible  questions,  but  in  order  that  the  student  may  learn 
to  distinguish  normal  conditions,  and  by  studying  the  reproduc- 
tions methodically,  recognize  the  normal  in  his  search  for  the 
abnormal. 

In  this  sense  the  recognition  of  the  normal  becomes  as  impor- 
tant as  does  that  of  the  abnormal,  and  the  student  is  taught  not 
to  overlook  anything — not  even  an  artifact. 

By  this  method,  if  reference  is  made  to  previous  normal  illus- 
trations, the  abnormal  can  readily  be  compared  with  the  normal 
conditions  of  the  same  part.  The  knowledge  acquired  from  this 
book  will  thus  approach  very  closely  to  that  obtained  from  the 
living  instructor,  and  the  student's  power  of  original  observation 
will  be  strengthened  and  improved. 

BeUeving,  as  I  do,  that  in  the  study  of  diseases  a  knowledge 
of  normal  conditions  should  first  be  mastered,  I  have  begun  my 
illustrations  by  showing  a  set  of  normal  Roentgenographs  covering 
the  different  stages  of  development  from  a  late  period  of  intra-uter- 
ine  life  through  childhood. 

I  have  then  given  the  results  of  my  study  of  the  bones  of  the 
wrist,  so  as  to  exemphfy  what  especial  practical  use  can  be  made 
from  an  exact  knowledge  of  the  Uving  anatomy  of  an  especial  part. 


PREFACE.  vii 

I  have  next  given  examples  of  what  can  be  seen  in  diseases  of 
the  new-born,  such  as  the  various  congenital  malformations  and 
such  abnormal  conditions  as  are  present  at  birth. 

By  this  portrayal  of  normal  living  anatomy  and  the  grosser 
forms  of  the  abnormal  conditions  the  student  is  prepared  to  under- 
stand the  finer  pathologic  lesions  in  the  living  subject. 

I  have  next  shown  the  characteristic  living  lesions  of  the  dis- 
eases of  nutrition.  I  have  then  divided  the  book  into  certain 
groups  which  represent  living  pathologic  conditions.  Thus,  in  one 
division  I  have  described  the  head  and  spine.  In  the  next  division 
I  have  given  in  detail  what  can  be  seen  in  Roentgenographs  of  the 
thorax,  describing  in  succession  abnormal  conditions  of  the  bronchial 
nodes,  the  bronchi,  the  lungs,  the  pleura,  the  pericardium,  the  heart, 
and  aneurism. 

In  the  next  division,  the  abdomen,  I  have  been  able  to  illus- 
trate the  various  conditions  to  only  a  limited  degree,  as  this  part  of 
the  infant  and  child  presents  great  difficulties  for  the  technic  of  the 
Roentgen  method. 

Next  I  have  shown  how  foreign  bodies  can  be  detected  in  dif- 
ferent parts  of  the  trunk  and  extremities.  Finally  I  have  grouped 
under  diseases  of  the  extremities,  for  obvious  technical  reasons,  a 
number  of  conditions  of  varying  etiology. 

The  material  which  illustrates  the  book  has  in  most  cases  been 
taken  from  the  Roentgen  records  of  the  Children's  Hospital,  and  I 
wish  to  express  my  appreciation  of  the  courtesy  of  the  Managers, 
who  have  permitted  me  to  use  what  has  amounted  in  the  past  year 
to  over  two  thousand  and  three  hundred  cases. 

The  plates  of  the  Roentgen  illustrations  were  taken  by  Dr. 
Arial  W.  George,  and  in  their  unusual  excellence  speak  for  them- 
selves. To  Dr.  George  I  can  only  express  my  appreciation  of  his 
skill  and  the  ever  new  light  which  he  has  thrown  upon  a  somewhat 
difficult  subject  by  his  clear  and  original  interpretation. 


yw.  PREFACE. 

To  Dr.  Percy  Brown  I  owe  my  thanks  for  much  expert  advice 
on  subjects  connected  with  the  writing  of  the  book  and  for  the  plates 
illustrating  long  and  short  exposures. 

To  Dr.  Walter  Curtis  Miner  I  wish  to  express  my  appreciation 
of  his  work  in  connection  with  those  illustrations  which  represent 
the  development  of  the  teeth  and  their  anomalies.  What  is  shown 
in  these  dental  Roentgenographs  will  be  of  great  service  not  only 
to  the  oral  surgeon  but  to  the  orthodontist  and  to  the  general 
practitioner. 

Dr.  William  Palmer  Lucas  has  given  much  practical  aid  in 
many  ways  connected  with  the  book,  and  to  him  are  due  my 
thanks. 

I  offer  this  work  to  the  Medical  Profession  in  the  hope  that  it 
may  be  of  assistance  in  solving  many  of  the  more  difficult  problems 
which  arise  in  the  diagnosis  of  disease  in  early  life. 

THOMAS  MORGAN  ROTCH. 


197  Commonwealth  Avenue,  Boston,  Massachusetts, 
January,  1910. 


TABLE   OF   CONTENTS 


rAOE 

INTRODUCTION 1 

DIVISION  I. 

LIVING  NORMAL  ANATOMY 17 

Bone;  Periosteum;  The  Constituents  of  Bone;  Diaphyses  and  Epiphyses;  Time  of 
the  Appearance  of  the  Epiphyses;  Development  of  Bone;  Humerus;  Radius;  Ulna; 
Carpus;  Metacarpus;  Phalanges;  Femur;  Patella;  Tibia;  Fibula;  Tarsus;  Meta- 
tarsus; Phalanges;  Os  Innominatum;  Teeth;  Temporary  Teeth;  Permanent  Teeth; 
Chronologic  Examples  of  Normal  Living  Anatomy. 

DIVISION  II. 

ILLUSTRATFVE  USE  OF  LIVING  NORMAL  ANATOMY 49 

Key  to  Index  Development;  State  Laws  regarding  Child  Labor. 

DIVISION  III. 

DISEASES  OF  THE  NT:W-B0RN 69 

Anomalies  of  the  Head,  Spine,  and  Ribs;  Spina  Bifida;  Intra-thoracic  and  Intra- 
abdominal Anomalies;  Anomalies  of  the  Extremities  and  Pelvis;  Backward  Mental 
Development;  Myxoedema;  Cretinism;  Chondrodystrophia  Foetahs;  Achondro- 
phasia;  Osteogenesis  Imperfecta;  Fetal  Rhachitis;  Obstetrical  Paralysis. 

DIVISION  IV. 

DISEASES  OF  NUTRITION 95 

Osteomalacia 96 

Infantile  Atrophy 99 

Scorbutus 100 

Rhachitis 104 

Rhachitis  of  Adolescence 112 

DIVISION  V. 

DISEASES  OF  THE  HEAD  AND  SPINE 115 

Supernumerary  Teeth;  Non-tubercular  Infections  of  Spine;  Osteomyelitis  of  Spine; 
Tuberculosis  of  Spine. 

ix 


X  TABLE  OF  CONTENTS. 

DIVISION  VI. 

THE   BRONCHIAL   NODES  —  BRONCHI  —  LUNGS  —  PLEURA  —  HEART  —  PERI- 
CARDIUM—ANEURISiM 131 

Bbonchiai.  Nodes 132 

Tuberculosis. 

Bronchi 133 

Lungs 133 

Atelectasis;  Emphysema;  Gangrene;  Tuberculosis;  Hydropneumothorax;  Pneumo- 
thorax; Bronchopneumonia;  Pneumonia. 

Pleura 137 

Empyema. 

Heart  . ." 139 

Pericardium 139 

Aneurism 140 

DIVISION  VII. 

THE  ABDOMEN 141 

Hour-glass  Contraction  of  Stomach;  Enlarged  Mesenteric  Nodes. 

DIVISION  VIII. 

FOREIGN  BODIES 143 

Urethra;  (Esophagus;  Larynx;  Lung;  Intestine;  Hip;  Knee-joint;  Foot;  Toe. 

DIVISION  IX. 

EXTREMITIES 149 

Hand;  Wrist;  Foot;  Abscess  of  .'^rm;  Sarcoma;  Atrophy;  PoliomyeUtis;  Sub- 
periosteal Hemorrhage;  Exostoses;  Callus;  Flat-foot;  Traumatism;  Fractures; 
Dislocations. 

JOINTS 163 

Knee:    Congestion 166 

Epiphysitis 166 

Osteochondritis 166 

Suppuration  of  Epiphysis 167 

Villous  Arthritis 167 

Ankylosis 168 

EPIPHYSITIS 175 

EPIPHYSIS  176 

Shoulder 176 

Elbow , .   176 

Wrist 177 

Hip 178 

Knee 178 

Ankle 179 

Os  Caclis 179 


TABLE  OF  CONTENTS. 


XI 


Clavicle 179 

Acromion 179 

CoRAOOiD  Processes  of  Scapula 179 

Ribs 179 

Vertebra 179 

Bones  of  Pelvis 179 

INFECTIOUS  ARTHRITIS 181 

Humerus 185 

Hand 185 

Knee 185 

Femur 186 

RHEUMATIC  FEVER 186 

Knee;  AnkJe. 

INFECTIOUS  PERIOSTITIS 186 

OSTEOMYELITIS 187 

Tibia 189,  191,  195,  196 

Femur 190,  192,  195 

Hip 191 

Elbow 192 

Humerus 193 

Radius 193 

Fibula 196 

HYPERTROPHY  ANT)  ATROPHY  OP  JOINTS 197 

Wrists 197 

Hands 197 

Arms 197 

Knees 197 

Legs 197 

Ankles 197 

SYPHILIS 198 

DAcrrrLiTis 199 

Elbow 200 

Ulna 200 

Tibia 201 

Osteoperiostitis 201 

Osteochondritis 201 

Periostitis 201 

Retarded 202 

TUBERCULOSIS 202 

Atrophy 207 

Dactylitis 209,  610,  211 

Metatarsus 209 

Atrophy  from  Disuse 210 

Ulna:     Necrosis 211 

Carpus 211 


xii  TABLE  OF  CONTENTS. 

Elbow 211 

Hip 211,  212,  213 

Acetabulum 212 

Femur 212 

Knee  213,  214 

Thigh  (Abscess) 214 

Ankle 215 

Astragalus 215 

Os  Calcis 215 

NON-TUBERCULAR  INFECTIONS 215 

Infection  of  Periosteum 217 

Infection  of  Marrow 217 


ILLUSTRATIONS 

(PLATES  ARE  GROUPED  AT  THE   END  OF  THE  DIVISION  THEY  ILLUSTRATE.) 


PLATE  DIV. 

1.  Examples  of  Comparative  Density IrUroditdion 

2.  Premature  Infant,  seven  months 

3.  Normal  Head,  age  ten  days 

4.  Normal  Trunk  and  Legs,  age  ten  days 

5.  Normal  Head,  age  ten  weeks 

6.  Normal  Pelvis,  Leg,  and  Foot,  age  ten  weeks 

7.  Normal  Hand,  age  three  months 

8.  Normal  Thorax,  Shoulders,  and  Elbows,  age  three  months 

9.  Normal  Infant,  age  six  months 

10.  Normal  Thorax,  age  twelve  months 

11.  Normal  Infant,  age  two  years 

12.  Normal  Infant,  age  three  years 

13.  Normal  Knees,  Lower  Legs,  and  Ankles,  age  three  years 

14.  Normal  Foot,  age  five  years 

15.  Normal  Child,  age  six  years 

16.  Normal  Shoulder,  age  six  years 

17.  Normal  Elbow,  age  six  years 

18.  Normal  Knee,  age  six  years 

19.  Normal  Thorax,  age  six  years 

20.  Normal  Hands,  boy,  age  nine  years 

21.  Normal  Child,  age  ten  years 

22.  Normal  Knees,  Lower  Legs,  and  Foot,  age  ten  years 

23.  Normal  Spine,  age  ten  years 

24.  Normal  Child,  age  twelve  years 

25.  Normal  Elbow,  age  twelve  years 

26.  Normal  Thorax,  boy,  age  twelve  years 

27.  Right  Side  of  Head,  boy,  age  thirteen  years 

28.  Normal  Hand — Group  A,  girl,  age  six  months I 

29.  Normal  Hand — Group  B,  girl,  age  two  and  three-fourths  years I 

30.  Normal  Hand — Group  C,  girl,  age  two  and  three-fourths  years I 

31.  Normal  Hand — Group  D,  boy,  age  two  and  one-fourth  years I 

32.  Normal  Hand — Group  E,  girl,  age  three  and  one-half  years I 

33.  Normal  Hand — Group  F,  girl,  age  five  and  one-half  years I 

34.  Normal  Hand — Group  G,  girl,  age  six  and  one-half  years I 

35.  Normal  Hand — Group  H,  girl,  age  six  years I 

36.  Normal  Hand — Group  I,  girl,  age  six  and  three-fourths  years I 

37.  Normal  Hand — Group  J,  girl,  »ge  eight  and  one-fourth  years I 

38.  Normal  Hand — Group  K,  girl,  age  eleven  and  one-fourth  years 1 

39.  Normal  Hand — Group  L,  girl,  age  eleven  and  three-fourths  years II 


xiv  ILLUSTRATIONS. 

PLATE  »"• 

40.  Normal  Hand — Group  M,  girl,  age  thirteen  and  one-half  years II 

41.  Anomaly  of  Upper  Cervical  Vertebra-,  boy,  age  six  years Ill 

42.  Spina  Bifida  C)ceulta,  girl,  age  three  and  one-half  years,  photograph Ill 

43.  Spina  Bifida  Occulta,  a  Roentgenograph  of  the  same  subject  as  Plates  42  and  44 Ill 

44.  Spina  Bifida  Occulta,  a  Roentgenograph  of  the  same  subject  as  Plates  42  and  43 Ill 

45.  Fusion  of  Ribs,  Marked  Scoliosis  of  Congenital  Origin,  child,  age  four  years Ill 

46.  Congenital  Torticollis,  boy,  age  six  years Ill 

47.  Congenital  Elevation  of  Scapula,  Left  Side,  boy,  age  six  years Ill 

48.  Congenital  Elevation  of  Right  Scapula,  boy,  age  six  years Ill 

49.  Congenital  Elevation  of  Right  Scapula,  infant,  age  six  months Ill 

50.  Webbed  Fingers,  Extra  Digit Ill 

51.  Congenital  Deformity  of  Hands  and  Arms,  boy,  age  ten  years Ill 

52.  Malformation  of  the  Radius  and  Ulna,  infant,  age  eight  months Ill 

53.  Congenital  Dislocation  of  the  Radius  and  Ulna,  boy,  age  ten  years Ill 

54.  Congenital  Deformity  of  Foot,  boy,  age  eight  years Ill 

55.  Roentgenograph  of  a  Congenital  Deformity  of  the  Foot Ill 

56.  Undeveloped  Foot,  child,  age  three  years Ill 

57.  Congenital  Delayed  Development  of  the  Right  Leg,  infant,  age  six  months.    (Morse) .  Ill 

58.  The  Feet  of  the  Same  Subject  as  Plate  57 Ill 

59.  Double  Congenital  Dislocation  of  the  Hip,  girl,  age  twelve  and  one-half  years Ill 

60.  Congenital  Dislocation  of  the  Left  Femur,  boy,  age  ten  years HI 

61.  Atrophy  in  Size  of  Both  Femora  due  to  Paralysis  of  the  Legs,  infant,  age  two  years  .  .  .  Ill 

62.  An  Anomalous  Condition  of  the  Second  Metacarpal  Bone Ill 

63.  Retarded  Development  of  Hand  Corresponding  with  Retarded  Development  of  Brain, 

boy,  age  four  years  and  nine  months Ill 

64.  Myxoedema— Retarded  Development,  girl,  age  eight  years Ill 

65.  Irregular  Development,  girl,  age  twenty-seven  months Ill 

66.  Chondrodystrophia  Foetalis,  girl,  age  five  and  one-half  years,  and  boy,  age  thirteen 

and  one-half  years Ill 

67.  Retarded  Development  of  the  Pisiform  Bone  and  General  Anomalous  Condition Ill 

68.  Osteogenesis  Imperfecta,  Hand  and  Forearm,  girl,  age  two  years Ill 

69.  Osteogenesis  Imperfecta,  Leg-fractures,  girl,  age  two  years Ill 

70.  Osteogenesis  Imperfecta,  Leg-fractures,  girl,  age  twenty-five  months Ill 

71.  Obstetrical  Paralysis  of  the  Left  Arm Ill 

72.  Obstetrical  Paralysis  of  the  Left  Arm,  Marked  Atrophy,  boy,  age  six  years Ill 

73.  Obstetrical  Paralysis  of  the  Right  Shoulder,  girl,  age  four  months Ill 

74.  Osteomalacia,  girl,  age  seven  years IV 

75.  Infantile  Atrophy,  infant,  age  twelve  months IV 

76.  Infantile  Scorbutus,  Thickened  Cortex  and  Periosteum,  girl,  age  eleven  months IV 

77.  Infantile  Scorbutus,  Subperiosteal,  girl,  age  eleven  months IV 

78.  Infantile  Scorbutus,  Organizing  Clot  and  Haematoma  of  the  Muscles,  infant,  age  six 

months IV 

79.  Infantile  Scorbutus,  same  subject  as  Plate  78 IV 

80.  Infantile  Scorbutus — Infiltrated  Muscles,  infant,  age  two  months IV 

81.  Early  Rhachitis,  child,  age  three  years IV 

82.  Early  Rhachitis,  cliild,  age  two  years IV 

83.  Rhachitis,  boy,  age  seven  years.    Photographs IV 

84.  Early  Rhachitis — Thickened  Cortex — Wolff's  Law,  boy,  age  seven  years IV 

85.  Advanced  Rhachitis,  boy,  age  ten  years IV 

86.  Marked  Rhachitis,  boy,  age  seven  years IV 


ILLUSTRATIONS.  xv 

PLATE  DIV, 

87.  Protuberant  Abdomen,  Knock-knee,  and  Flat-foot,  boy,  age  three  years IV 

88.  Rhachitis  of  Adolescence — Normal  and  Rhachitic  Hands,  boys,  age  thirteen  years ....  IV 

89.  Rhachitis  of  Adolescence — Hand,  child,  age  twelve  years IV 

90.  Fracture  of  Skull,  boy,  age  thirteen  years V 

91.  Ethmoiditis,  child,  age  three  years V 

92.  Osteomyelitis  of  Lower  Jaw,  colored  boy,  age  twelve  years V 

93.  Amomalous  Bicuspids — Left  Side  of  Head,  boy,  age  thirteen  years V 

94.  Anomalous  Lower  Biscupid — Right  Side  of  Head,  boy,  age  thirteen  years V 

95.  Unerupted  Permanent  Teeth — Right  Side  of  Head,  boy,  age  eight  years V 

96.  Supernumerary  Tooth — Left  Side  of  Head,  boy,  age  fifteen  years V 

97.  Supernumerary  Tooth — Right  Side  of  Head,  girl,  age  fourteen  years V 

98.  Supernumerary  Tooth — Left  Side  of  Head,  girl,  age  fourteen  years V 

99.  Various  Anomalous  Conditions  Connected  with  the  Teeth V 

100.  Rhachitis  of  Spine,  colored  boy,  age  six  years V 

101.  Osteomyelitis  of  Vertebrae,  girl,  age  four  years V 

102.  Tuberculosis  of  the  Spine,  IHum,  and  Left  Hip V 

103.  Tuberculosis  of  the  Ilium V 

104.  Tubercular  Abscess  of  the  Spine V 

105.  Tuberculosis  of  the  Spine,  child,  age  four  years V 

106.  Tubercular  Spine,  the  same  subject  as  Plate  105,  lateral  view V 

107.  Normal  Thorax,  girl,  age  seven  years.     Long  exposure.     (Brown) VI 

108.  Normal  Thorax,  girl,  age  seven  years.     Short  exposure.     (Brown) VT 

109.  Enlarged  Bronchial  Nodes,  girl,  age  twelve  years VI 

110.  Transposition  of  Organs — Tuberculosis  of  the  Lungs  and  Bronchial  Nodes VI 

111.  Pneumococcus  Lobar  Pneumonia VI 

112.  Double  Pneumococcus  Lobar  Pneumonia,  boy,  age  twelve  years VI 

113.  Lobar  Pneumonia,  child,  age  ten  years VI 

114.  Unresolved  Lobar  Pneumonia,  girl,  age  four  years Yl 

115.  Lobar  Pneumonia,  girl,  age  twenty-seven  months.    Same  subject  as  Plates  65,  116, 

and  117 VI 

116.  Consolidation  of  Right  Lung — Mongolian  Idiot VI 

117.  Lobar  Pneumonia.     Same  subject  as  Plates  65,  115,  and  116 VI 

lis.  Bronchopneumonia,  child,  age  four  years VI 

119.  Pneumonia — Inhalation  of  China  Doll's  Arm.     Same  subject  as   Plates  148,   149, 

and  150 VI 

120.  Acute  Miliary  Tuberculosis  of  the  Lungs,  boy,  age  ten  years VI 

121.  Early  Miliary  Tuberculosis  of  the  Lungs,  child,  age  three  years VI 

122.  Probable  Old  Tubercular  Process  of  Lung — Calcification VI 

123.  Emphysema,  Gangrene,  and  Tuberculosis  oi  the  Left  Lung,  girl,  age  three  years VI 

124.  Acute  MiUary  Tuberculosis  of  Both  Lungs,  girl,  age  twelve  years VI 

125.  Hydropneumothorax,  boy,  age  seven  years.     Same  subject  as  Plates  126  and  127. ...  VI 

126.  Hydropneumothorax.     Same  subject  as  Plates  125  and  127 VI 

127.  Pneumothorax.     Same  subject  as  Plates  125  and  126 VI 

128.  Thickened  Pleura,  boy,  age  six  years VI 

129.  Pleurisy  with  Effusion,  child,  age  eight  years VI 

130.  CoUap.sed  Ribs,  girl,  age  six  years VI 

131.  Encapsulated  Empyema,  boy.  age  ten  years VI 

132.  Dilated  Heart,  boy,  age  ten  years yj, 

133.  Pericardial  Effusion,  child,  age  twelve  years VI 

134.  Enlarged  Heart  with  Pericardial  Effusion,  child,  age  twelve  years VI 


xvi  ILLUSTRATIONS. 

FLATE  "I^- 

135.  Pericardial  Effusion  and  Obliteration  of  the  Cardiohepatic  Angle VI 

136.  Aneurism,  boy,  age  twelve  years VI 

137.  Normal  Abdomen,  boy,  age  nine  years.     Short  exposure.    (Brown) VII 

138.  Normal  Abdomen,  boy,  age  nine  years.     Long  exposure.  (Brown).    Same  subject  as 

Plate  137 VII 

1.39.  Hour-glass  Contraction  of  Stomach,  infant,  age  five  weeks VII 

140.  Hour-glass  Ck)ntraction  of  Stomach — Tube  in  Stomach.     Same  subject  as  Plate  139  VII 

141.  Abdominal  Ascites,  girl,  age  twelve  years VII 

142.  Calcified  Mesenteric  Nodes VII 

143.  Stone  in  Urethra,  Encapsulating  a  Pin,  giri,  age  thirteen  years VIII 

144.  Foreign  Body  in  Intestine,  boy,  age  five  years VHI 

145.  Foreign  Body  in  (Esophagus VIII 

146.  Hook  in  the  Larynx,  child,  age  four  years VIII 

147.  Nail  in  Right  Lung VIII 

148.  Doll's  China  Arm  in  Lung,  girl,  age  four  years.     Same  subject  as  Plates  119,  149, 

and  150 VIII 

149.  Doll's  China  .\rm  in  Lung.    Samesubject  as  Plates  119,  148,  and  150,  taken  facedown.  VIII 

150.  Doll's  China  Arm  in  Lung.    Same  subject  as  Plates  119,  148,  and  149 VIII 

151.  Penny  in  the  Descending  Colon VIII 

152.  Needle  in  the  Knee-joint.     Same  subject  as  Plate  153 VIII 

153.  Needle  in  the  Knee-joint.     Same  subject  as  Plate  152,  different  position VIII 

154.  Needle  in  Foot.     Same  subject  as  Plate  155 VIII 

155.  Needle  in  Foot.    Same  subject  as  Plate  154,  different  position VIII 

156.  Needle  in  the  Tissues  around  the  Phalanx  of  the  Little  Toe VIII 

157.  Retarded  Development  of  Hand,  boy,  age  eight  years IX 

158.  Premature  Ossification  of  the  Lower  Epiphysis  of  the  Radius — Sesamoid  Bone,  child, 

age  thirteen  years IX 

159.  Delayed  Development  of  the  Scaphoid,  boy,  age  six  years IX 

160.  Early  Ossification  of  the  Upper  Epiphysis  of  the  Tibia IX 

161.  Cellulitis  of  Tissues  of  Left  Arm,  boy,  age  nine  years IX 

162.  Hematoma  of  Heel,  child,  age  twelve  years IX 

163.  Giant-celled  Sarcoma  of  the  Thigh,  boy,  age  foiu"  and  one-half  years IX 

164.  Medullary  Sarcoma  of  the  Lower  Part  of  the  Femur,  boy,  age  twelve  years IX 

165.  Periosteal  Sarcoma — Lower  End  of  Femur,  boy,  age  ten  years IX 

166.  Extreme  Atrophy,  boy,  age  thirteen  years IX 

167.  Anterior  Poliomyelitis  of  the  Right  Hand  and  Wrist,  infant,  age  eighteen  months. ...  IX 

168.  Anterior  PoUomyelitis  of  the  Left  Shoulder,  boy,  age  twelve  months IX 

169.  Anterior  Poliomyelitis  of  the  Left  Arm,  child,  age  four  years IX 

170.  Subperiosteal  Hemorrhage  of  the  Left  Leg IX 

171.  Exostosis  of  Astragalus,  boy,  age  twelve  years IX 

172.  Multiple  Exostoses  of  Tibia  and  Fibula,  boy,  age  five  years IX 

173.  Multiple  Exostoses — Leg,  boy,  age  five  years IX 

174.  Exostosis  of  the  Lower  Part  of  the  Femur IX 

175.  Exostosis  of  the  Tibia,  boy,  age  twelve  years IX 

176.  Calluses  of  Feet,  girl,  age  ten  years IX 

177.  -Abnormally  High  Arch  of  Foot,  girl,  age  ten  years IX 

178.  Moderate  Flat-foot,  girl,  age  thirteen  years IX 

179.  Backward  Displacement  of  the  Inner  Condyle  of  the  Femur,  boy,  age  twelve  years. . .  IX 

180.  Fracture  and  Displacement  of  the  Head  of  the  Humerus IX 

181.  Dislocation  and  Fracture  of  the  Anatomic  Head  of  the  Himierus,  boy,  age  eleven  years  IX 


ILLUSTRATIONS.  xvii 

PLATE  DIV. 

182.  Fracture  of  the  Neck  of  the  Humerus,  boy,  age  twelve  years IX 

183.  Impacted  Fracture  of  the  Surgical  Neck  of  the  Humerus,  boy,  age  four  years IX 

184.  Dislocation  of  the  Epiphysis  of  the  Femur,  boy,  age  five  years IX 

185.  Untreated  but  United  Green-stick  Fracture  of  the  Tibia,  boy,  age  eight  years IX 

186.  Intracapsular  Fracture  of  the  Femur,  boy,  age  ten  years IX 

187.  Dislocation  of  the  Lower  End  of  the  Femur,  boy,  age  ten  years IX 

188.  Fracture  of  the  Lower  End  of  the  Humerus  with  Inward  Displacement  of  the  Lower 

Fragment,  boy,  age  ten  years » IX 

189.  Green-stick  Fracture  of  the  Radius,  girl,  age  twelve  years IX 

190.  Complete  Fracture  of  the  Lower  Third  of  the< Radius  and  Ulna  with  Impaction,  child, 

age  three  to  four  years IX 

191.  Complete  Fracture  of  the  Radius  and  Ulna,  child,  age  three  years IX 

192.  Incomplete  Fracture  of  the  Lower  End  of  the  Tibia,  infant,  age  twelve  months .:....  IX 
19.3.  Fracture  of  the  Astragalus,  boy,  age  eleven  years IX 

194.  Old  Fracture  of  Tibia  and  Fibula,  with  Connecting  Bridge IX 

195.  Normal  Foot,  child,  age  ten  years IX 

196.  Fracture  of  Tibia  with  Compensatorj-  Growth  of  Fibula,  girl,  age  twelve  years IX 

197.  Congestion  of  the  Knee  in  a  Case  of  Chronic  Arthritis,  child,  age  six  years IX 

198.  Epiphysitis  of  the  Knee-joint,  boy,  age  one  year IX 

199.  Epiphysitis  of  the  Upper  Epiphysis  of  the  Tibia,  girl,  age  ten  years IX 

200.  Infectious  Arthritis — Atrophic  Type,  girl,  age  three  years IX 

201.  Villous  Arthritis,  girl,  age  twelve  years IX 

202.  Ankylosis  of  Knee-joint,  boy,  age  thirteen  years IX 

203.  Infectious  Arthritis  in  Shoulder-joint,  girl,  age  eight  years IX 

204.  Infectious  Arthritis  of  Hands IX 

205.  Infectious  Arthritis  of  the  Hand,  boy,  age  four  and  one-half  years IX 

206.  Effusion  in  the  Knee-joint,  boy,  age  ten  years IX 

207.  Acute  Arthritis  of  Right  Hip,  child,  age  eight  months IX 

208.  Rheumatic  Fever — Knee-joint IX 

209.  Rheumatic  Fever — Ankle-joint IX 

210.  Osteomyelitis  of  the  Shaft  of  the  Tibia,  child,  age  nine  years IX 

211.  Chronic  Osteomyelitis  of  the  Shaft  of  the  Femur IX 

212.  The  Results  of  an  Acute  Destructive  Process  in  the  Hips,  child,  age  five  years IX 

213.  Osteomyelitis  of  the  Upper  Shaft  of  the  Tibia  and  of  the  Epiphysis,  boy,  age  eight  years  IX 

214.  Acute  Osteomyelitis  of  the  Right  Femur,  child,  age  two  years IX 

215.  Chronic  Osteomyelitis— Great  Destruction  of  the  Femur,  child,  age  two  years IX 

216.  Osteomyelitis  of  Elbow,  boy,  age  nine  years IX 

217.  Typhoidal  Osteomyelitis,  child,  age  eight  years IX 

218.  Osteomyelitis  of  the  Lower  End  of  the  Radius,  boy,  age  six  years IX 

219.  Osteomyelitis  of  Lower  Arm IX 

220.  Osteomyelitis  of  the  Acetabulum  with  Sequestrum,  child,  age  two  and  one-half  years.  .  IX 

221.  Osteomyehtis  of  the  Femur,  child,  age  seven  years IX 

222.  Osteomyelitis  near  Hipt-joint — Pneumococcus  Infection,  child,  age  three  and  one-half 

}-ears IX 

223.  Osteomyehtis  near  Hip-joint,  child,  age  four  and  one-half  years IX 

224.  Mixed  Infection  of  Hip-joint — Probable  Osteomyehtis,  girl,  age  six  years IX 

225.  Osteomyelitis  of  Lower  End  of  Tibia,  boy,  age  twelve  years IX 

226.  Osteomyelitis  of  the  Lower  End  of  the  Right  Femur,  boy,  age  seven  years IX 

227.  Osteomyehtis  of  the  Upper  End  of  the  Left  Tibia,  boy,  age  twelve  years IX 

228.  Early  Stage  of  Osteomyehtis  of  the  Lower  Extremity  of  the  Tibia,  boy,  age  twelve  years  IX 

B 


xviii  ILLUSTRATIONS. 

PLATE  '"V- 

229.  Osteomyelitis  of  Fibula,  girl,  age  eleven  years IX 

230.  Undetermined  Infection  of  the  Lower  Epiphysis  of  the  Tibia,  boy,  age  ten  years IX 

231.  Chronic  Infectious  OstcomycUtis  of  the  Upper  End  of  the  Tibia,  boy,  age  six  years. . .  IX 
2.32.  Atrophic  Condition  of  Hands,  boy,  age  twelve  years IX 

233.  Chronic  Atrophic  Condition  of  the  Knee-joints,  boy,  age  eight  years IX 

234.  An  Infectious  Arthritis  of  the  Knee-joint — C'hronic  Atrophic  Condition IX 

235.  Syphilis  of  the  Lower  End  of  the  Humerus,  boy,  age  eleven  years IX 

236.  Syphilis  of  tlie  Elbow  and  Forearm IX 

237.  Syphilitic  Dactylitis,  child,  age  two  years IX 

238.  Syphilitic  Periostitis,  child,  age  five  years IX 

239.  Syphilitic  Periostitis  in  Shaft  of  Tibia,  boy,  age  eight  years IX 

240.  Syphilitic  Osteoperiostitis  and  Osteochondritis,  child,  age  six  weeks.     (La  F6tra) IX 

241.  Syphilis  of  Lower  End  of  Tibia,  girl,  age  twelve  years IX 

242.  Infect  ion  of  Metatarsal  Bone,  girl,  age  twelve  years.    Tubercular  Dactylitis,  child,  age 

three  years IX 

243.  Atrophy  of  Knee  from  Disuse,  girl,  age  twelve  years IX 

244.  Tubercular  Dactylitis,  girl,  age  two  and  one-half  years IX 

245.  Tubercular  Dactylitis,  child,  age  three  years IX 

246.  Tuberculosis  of  the  Lower  Part  of  the  Shaft  of  the  Ulna,  child,  age  three  years IX 

247.  Tuberculosis  of  the  Carpal  Bones,  boy,  age  five  years IX 

248.  Tuberculosis  in  Elbow-joint,  girl,  age  eight  years IX 

249.  Probable  Mixed  Infection  of  Hip-joint,  child,  age  five  years IX 

250.  Tuberculosis  of  the  Femur  and  Acetabulum,  boy,  age  twelve  years IX 

251.  Mixed  Infection  of  the  Hip-joint  and  Acetabulum,  child,  age  five  years IX 

252.  The  End  Result  of  an  Old  Tubercular  Process,  child,  age  fourteen  years IX 

253.  Probable  Tubercular  Infection  of  the  Epiphyses,  child,  age  eight  years IX 

254.  An  Infectious  Process  in  the  Neck  of  the  Femur,  child,  age  five  years IX 

255.  Typical  Tuberculosis  of  the  Left  Hip-joint — Marked  Porosity  of  the  Left  Side,  girl, 

age  eight  years IX 

256.  Questionable  Infection  of  the  Knee-joint  (probably  Tuberculosis) — Infiltration  of  the 

Tissues,  boy,  age  five  years IX 

257.  Typical  Tuberculosis  of  the  Ivnee-joint,  boy,  age  eight  years IX 

258.  Abscess  of  the  Thigh,  boy,  age  six  years IX 

259.  Tuberculosis  of  the  Epiphysis  of  the  Tibia,  child,  age  nine  years IX 

260.  Tuberculosis  of  the  Os  C'alcis,  child,  age  two  and  one-half  years IX 

261.  Tubercular  Infection  of  the  Epiphysis  and  Astragalus,  child,  age  four  years IX 

262.  Tuberculosis  of  the  Epiphysis  of  the  Tibia,  child,  age  five  years IX 

263.  Acute  Tubercular  Infection  of  the  Os  Calcis,  boy,  age  twelve  years IX 

264.  Non-tubercular  Infection  about  the  Neck  of  the  Femur,  child,  age  five  years IX 


ILLUSTRATIONS 

(ARRANGED  ACCORDING  TO  THE  AGE  OF  THE  SUBJECT.) 


FIRST  YEAR. 

PLATE  DIV. 

Premature  Infant,  seven  months 2  I 

Normal  Head,  age  ten  days 3  I 

Normal  Trunk  and  Legs,  age  ten  days 4  I 

Hour-glass  Contraction  of  Stomach,  infant,  age  five  weeks 139  VII 

Hour-glass  Contraction  of  Stomach — Tube  in  Stomach,  infant,  age  five  weeks 140  VII 

Syphilitic  Osteoperiostitis  and  Osteochondritis,  child,  age  six  weeks  (La  Fetra) ....  240  IX 

Webbed  Fingers,  child,  age  two  months 50  III 

Infantile  Scorbutus,  infant,  age  two  months 80  IV 

Normal  Head,  infant,  age  ten  weeks 5  I 

Normal  Pehas,  Leg  and  Foot,  infant,  age  ten  weeks 6  I 

Normal  Hand,  infant,  age  three  months 7  I 

Normal  Thorax,  Shoulders  and  Elbows,  infant,  age  three  months 8  I 

Obstetrical  Paralysis  of  Right  Shoulder,  girl,  age  four  months 73  III 

Normal  Infant,  age  six  months 9  I 

Normal  Hand,  Group  A,  girl,  age  six  months 28  II 

Congenital  Elevation  of  Right  Scapula,  infant,  age  six  months 49  III 

Congenital  Delayed  Development  of  Right  Leg,  infant,  age  six  months  (Morse) 57  III 

The  feet  of  the  same  subject  as  Plate  57,  an  infant,  age  six  months 58  HI 

Infantile  Scorbutus,  Organizing  Clot  and  Haematoma  of  the  Muscles,  infant,  age  six 

months 78  IV 

Infantile  Scorbutus,  age  six  months 79  IV 

Malformation  of  the  Radius  and  Ulna,  infant,  age  eight  months 52  HI 

Acute  Arthritis  of  Right  Hip,  child,  age  eight  months 207  IX 

Infantile  Scorbutus,  Thickened  Cortex  and  Periosteum,  girl,  age  eleven  months 76  IV 

Infantile  Scorbutus,  Subperiosteal,  girl,  age  eleven  months 77  IV 

Normal  Thorax,  child,  age  twelve  months 10  I 

Anterior  Poliomyelitis  of  the  Left  Shoulder,  boy,  age  twelve  months 168  DC 

Infantile  Atrophy,  infant,  age  twelve  months 75  IV 

Incomplete  Fracture  of  the  Lower  End  of  the  Tibia,  infant,  age  twelve  months 192  IX 

SECOND  YEAR. 

EpiphjTsitis  of  the  Knee-joint,  boy,  age  one  year 198  IX 

Extra  Digit,  child,  age  one  and  one-half  years 50  III 

Anterior  Poliomyelitis  of  the  Right  Hand  and  Wrist,  infant,  age  eighteen  months.. .   167  IX 
An  Anomalous  Condition  of  the  Second  Metacarpal  Bone,  infant,  age  twenty-three 

months 62  III 

zix 


XX  ILLUSTRATIONS. 

THIRD  YEAR. 

PLATE  DIV. 

Normal  Infant,  age  two  years 11  I 

Atrophy   in  Size  of  both  Femora  due  to  Paralysis  of  the  Legs,  infant,  age   two 

years 61  III 

Osteogenesis  Imperfecta,  Hand  and  Forearm,  girl,  age  two  years 68  III 

Osteogenesis  Imperfecta,  Leg-fractures,  girl,  age  two  years 69  III 

Early  Rhachitis,  child,  age  two  years 82  IV 

Acute  Osteomyelitis  of  the  Right  Femur,  child,  age  two  years 214  IX 

Chronic  Osteomyelitis — Great  Destruction  of  the  Femur,  child,  age  two  years 215  IX 

Syphilitic  Dactylitis,  child,  age  two  years 237  IX 

Osteogenesis  Imperfecta,  Leg-fractures,  child,  age  twenty-five  months 70  III 

Irregular  Development,  girl,  age  twenty-seven  months 65  III 

Lobar  Pneumonia,  girl,  twenty-seven  months 115  VI 

Consolidation  of  Right  Lung — Mongolian  idiot,  girl,  age  twenty-seven  months 116  VI 

Lobar  Pneumonia,  girl,  age  twenty-seven  months — Same  subject  as  Plates  65,  115, 

and  116 117  VI 

Normal  Hand,  Group  D,  boy,  age  two  and  one-fourth  years 31  II 

Osteomyelitis  of  the  Acetabulum  with  Sequestrum,  child,  age  two  and    one-half 

years 220  IX 

Syphilis  of  Elbow,  girl,  age  two  and  one-half  years 236  IX 

Tubercular  Dactylitis,  girl,  age  two  and  one-half  years 244  IX 

Tuberculosis  of  the  Os  Calcis,  child,  age  two  and  one-half  years 260  IX 

Normal  Hand,  Group  B,  girl,  age  two  and  three-fourths  years 29  II 

Normal  Hand,  Group  C,  girl,  age  two  and  three-fourths  years 30  II 

FOURTH  YEAR. 

Normal  Infant,  age  three  years 12  I 

Normal  Knees,  Lower  Legs  and  Ankles,  child,  age  three  years 13  I 

Undeveloped  Foot,  child,  age  three  years 56  III 

Early  Rhachitis,  child,  age  three  years 81  IV 

Protuberant  Abdomen,  Knock-Knee,  and  Fiat-Foot,  boy,  age  three  years 87  IV 

Ethmoiditis,  child,  age  three  years 91  V 

Pneumococcus  Lobar  Pneumonia,  girl,  age  three  years Ill  VI 

Early  Miliary  Tuberculosis  of  the  Lungs,  child,  age  three  years 121  VI 

Emphysema,  Gangrene,  and  Tuberculosis  of  the  Left  Lung,  child,  age  three  years. .  123  VI 

Complete  Fracture  of  the  Radius  and  Ulna,  child,  age  three  years 191  IX 

Infectious  Artliritis — Atrophic  Type,  girl,  age  three  years 200  IX 

Tubercular  Dactylitis,  child,  age  three  years 242  IX 

Tubercular  Dactylitis,  child,  age  three  years 245  IX 

Tuberculosis  of  the  Lower  Part  of  the  Shaft  of  the  Ulna,  child,  age  three  years 246  IX 

Osteomyelitis  near  Hip-joint — Pneumococcus  Infection,  child,  age  three  and  one-half 

years 222  IX 

Normal  Hand,  Group  E,  girl,  age  three  and  one-half  years 32  II 

Spina  Bifida  Occulta,  girl,  age  three  and  one-half  years.     Photograph 42  III 

Spina  Bifida  Occulta,  a  Roentgenograph  of  the  same  subject  as  Plates  42  and  44. .  .  43  III 

Spina  Bifida  Occulta,  a  Roentgenograph  of  the  same  subject  as  Plates  42  and  43. .  .  44  III 
Complete  Fracture  of  the  Lower  Third  of  the  Radius  and  Ulna  with  Impaction,  child, 

age  three  to  four  years 190  IX 


ILLUSTRATIONS.  xxi 
FIFTH  YEAR. 

PLATE  DIV. 

Fusion  of  Ribs — Marked  Scoliosis  of  Congenital  Origin,  child,  age  four  years 45  III 

Osteomyelitis  of  Vertebrae,  girl,  age  four  years 101  V 

Tuberculosis  of  the  Spine,  child,  age  four  years 105  V 

Tuberculosis  of  the  Spine.    Same  Subject  as  Plate  105 — Lateral  View 106  V 

Unresolved  Lobar  Pneumonia,  girl,  age  four  years 114  VI 

Bronchopneumonia,  child,  age  four  years 118  VI 

Pneumonia — Inhalation  of  China  Doll's  Arm,  girl,  age  four  years 119  VI 

China  Doll's  Arm  in  Lung — Same  Subject  as  Plates  119,  149,  and  150 148  VIII 

China  Doll's  Arm  in  Lung — Same  Subject  as  Plates  119,  148,  and  150 149  VIII 

China  Doll's  Arm  in  Lung — Same  Subject  as  Plates  119,  148,  and  149 150  VIII 

Hook  in  the  Larynx,  child,  age  four  years 146  VIII 

Anterior  Poliomyelitis  of  the  Left  Arm,  child,  age  four  years 169  IX 

Impacted  Fracture  of  the  Surgical  Neck  of  the  Humerus,  boy,  age  four  years 183  IX 

Tubercular  Infection  of  the  Epiphysis  and  Astragalus,  child,  age  four  years 261  IX 

Syphilis  of  Forearm,  girl,  age  four  and  one-fourth  years 2.36  IX 

Giant-celled  Sarcoma  of  the  Thigh,  boy,  age  four  and  one-half  years 163  IX 

Infectious  Arthritis  of  the  Hand,  boy,  age  four  and  one-half  years 205  IX 

Osteomyelitis  near  Hip-joint,  child,  age  four  and  one-half  years 223  IX 

Retarded  Development  of  Hand,  boy,  four  years  and  nine  months 63  III 

SIXTH  YEAR. 

Normal  Foot,  child,  age  five  years 14  I 

Foreign  Body  in  Intestine,  boy,  age  five  years 144  VIII 

Multiple  Exostoses  of  Tibia  and  Fibula,  boy,  age  five  years 172  IX 

Multiple  Exostoses — Leg,  boy,  age  five  years 173  IX 

Dislocation  of  the  Epiphysis  of  the  Femur,  boy,  age  five  years 184  IX 

The  Results  of  an  Acute  Destructive  Process  in  the  Hips,  child,  age  five  years 212  IX 

Syphilitic  Periostitis,  child,  age  five  years 238  IX 

Tuberculosis  of  the  Carpal  Bones,  boy,  age  five  years 247  IX 

Probable  Mi.xed  Infection  of  the  Hip-joint,  child,  age  five  years 249  IX 

Mixed  Infection  of  the  Hip-joint  and  Acetabulum,  child,  age  five  years 251  IX 

An  Infectious  Process  in  the  Neck  of  the  Femur,  child,  age  five  years 254  IX 

Questionable  Infection  of  the  Knee-joint  (probably  tuberculosis),  boy,  age  five  years  256  IX 

Tuberculosis  of  the  Epiphysis  of  the  Tibia,  child,  age  five  years 262  IX 

Non-tubercular  Infection  about  the  Neck  of  the  Femur,  child,  age  five  years 264  IX 

Chondrodystrophia  Foetalis,  girl,  age  five  and  one-half  years 66  III 

Normal  Hand,  Group  F,  girl,  age  five  and  one-half  years 33  II 

SEVENTH  YEAR. 

Normal  Child,  age  six  years  15  I 

Normal  Shoulder,  child,  age  six  years 16  I 

Normal  Elbow,  child,  age  six  years 17  I 

Normal  Knee,  child,  age  six  years 18  I 

Normal  Thorax,  child,  age  six  years 19  I 

Normal  Hand,  Group  H,  child,  age  six  years 35  II 

Anomaly  of  Upper  Cervical  Vertebra;,  boy,  age  six  years 41  III 

Congenital  Torticollis,  boy,  age  six  years 46  III 


xxii  ILLUSTRATIONS. 

PLATS  DIV. 

Congenita!  Elevation  of  Scapula.     Left  Side,  boy,  age  six  years 47  III 

Congenital  Elevation  of  Kight  Scapula,  boy,  iige  six  years 48  III 

Obstetrical  Paralysis  of  the  Left  .\rni— Marked  Atrophy,  boy,  age  six  years 72  III 

Rhachitis  of  Spine,  colored  boy,  age  six  years 100  V 

Thickened  Pleura,  boy,  age  six  years 128  VI 

Collapsed  Ribs,  girl,  age  si.x  years 130  VI 

Delayed  Development  of  the  Scaphoid,  boy,  age  six  years 159  IX 

Congestion  of  the  Knee  in  a  Case  of  Chronic  Arthritis,  child,  age  six  years 197  IX 

Osteomyelitis  of  the  Lower  End  of  the  Radius,  boy,  age  six  years 218  IX 

Mixed  Infection  of  the  Hip-joint,  Probable  Osteomyelitis,  girl,  age  six  years 224  IX 

Oironic  Infectious  Osteomyelitis  of  the  Upper  End  of  the  Tibia,  boy,  age  six  years.   2.31  IX 

.\bsccss  of  the  Thigh,  boy,  age  six  years 258  IX 

Normal  Hand,  Group  G,  girl,  age  six  and  one-half  years 34  II 

Normal  Hand,  Group  I,  girl,  age  six  and  three-fourths  years 36  II 

EIGHTH  YEAR 

Osteomalacia,  girl,  age  seven  years 74  IV 

Rhachitis,  boy,  age  seven  years.     Photographs 83  IV 

Early  Rhachitis— Thickened  Cortex— Wolff's  Law— boy,  a^e  seven  years 84  IV 

Marked  Rhachitis,  boy,  age  seven  years 86  IV 

Normal  Thorax,  girl,  age  seven  years- Long  Exposure.     (Brown) 107  VI 

Normal  Thorax,  girl,  age  seven  years — Short  Exposure.     (Brown) 108  VI 

Hydropneumothorax,  boy,  age  seven  years 125  VI 

Hydropneumothorax,  boy,  age  seven  years,  the  Same  Subject  as  Plates  125  and  127  126  VI 

Osteomyelitis  of  the  Femur,  child,  age  seven  years 221  IX 

Osteomyelitis  of  the  Lower  End  of  the  Right  Femur,  boy,  age  seven  years 226  IX 

NINTH  YEAR. 

Congenital  Deformity  of  Foot,  boy,  age  eight  years 54  III 

Myxcedema — Retarded  Development — girl,  age  eight  years 64  III 

ObstetriciU  Paralysis  of  the  Left  Arm,  boy,  age  eight  years 71  III 

Unerupted  Permanent  Teeth — Right  Side  of  Head,  boy,  age  eight  years 95  V 

Pneumothorax,  boy,  age  eight  years.     Same  subject  as  Plates  125  and  126 127  VI 

Pleurisy  with  Effusion,  child,  age  eight  years 129  VI 

Retarded  Development  of  Hand,  boy,  age  eight  years 157  IX 

Untreated  but  United  Green-stick  Fracture  of  tlie  Tibia,  boy,  age  eight  years 185  IX 

Infectious  Arthritis  of  the  Shoulder-joint,  girl,  age  eight  years 203  IX 

Infectious  ,\rthritis  of  Hands,  girl,  age  eight  years 204  IX 

Osteomyelitis  of  the  Upper  Shaft  of  the  Tibia  and  of  the  Epiphysis,  boy,  age  eight 

years 213  IX 

Typhoidal  Osteomyelitis,  child,  age  eight  years 217  IX 

Chronic  Atrophic  Condition  of  tlie  Knee-joints,  boy,  age  eight  years 233  IX 

An  Infectious  Arthritis  of  the  Knee-joint,  boy,  age  eight  years 234  IX 

Syphilitic  Periostitis  of  the  Shaft  of  the  Tibia,  boy,  age  eight  years 239  IX 

Tuberculosis  of  the  Elbow-joint,  girl,  age  eight  years 248  IX 

Probable  Tubercular  Infection  of  the  Epiphyses,  child,  age  eight  years •.   253  IX 

Typical  Tuberculosis  of  the  Left  Hip-joint,  girl,  age  eight  years 255  IX 

Typical  Tuberculosis  of  the  Knee-joint,  boy,  age  eight  years 257  IX 

Normal  Hand,  Group  J,  girl,  age  eight  and  one-fourth  years 37  II 


ILLUSTRATIONS.  xxiii 
TENTH  YEAR. 

rLATB  DIV. 

Normal  Hands,  boy,  age  nine  years 20  I 

Normal  Abdomen,  boy,  age  nine  years.    Short  Exposure.     (Brown) 137  VII 

Normal  Abdomen,  boy,  age  nine  years.     Long  Exposure.     (Brown) 138  VII 

Cellulitis  of  Tissues  of  Left  Arm,  boy,  age  nine  years 161  IX 

Osteomyelitis  of  the  Shaft  of  the  Tibia,  child,  age  nine  years 210  IX 

Osteomyelitis  of  Elbow,  boy,  age  nine  years 216  IX 

Tuberculosis  of  the  Epiphysis  of  the  Tibia,  child,  age  nine  years 259  IX 

ELEVENTH  YEAR. 

Normal  Child,  age  ten  years 21  I 

Normal  Knees,  Lower  Legs  and  Foot,  child,  age  ten  years 22  I 

Normal  Spine,  child,  age  ten  years 23  I 

Congenital  Deformity  of  Hands  and  Arms,  boy,  age  ten  years 51  III 

Congenital  Dislocation  of  the  Radius  and  LHna,  boy,  age  ten  years 53  III 

Congenital  Dislocation  of  the  Left  Femur,  boy,  age  ten  years 60  III 

Advanced  Rhachitis,  boy,  age  ten  years 85  IV 

Lobar  Pneumonia,  boy,  age  ten  years 113  VI 

Acute  Miliary  Tuberculosis  of  the  Lungs,  boy,  age  ten  years 120  VI 

Encapsulated  Empyema,  boy,  age  ten  years 131  VT 

Dilated  Heart,  boy,  age  ten  years 132  VI 

Periosteal  Sarcoma — Lower  End  of  Femur,  boy,  age  ten  years 165  EX 

Calluses  of  Feet,  girl,  age  ten  years 176  IX 

Abnormally  High  Arch  of  Foot,  girl,  age  ten  years 177  IX 

Intracapsular  Fracture  of  the  Femur,  boy,  age  ten  years 186  IX 

Dislocation  of  the  Lower  End  of  the  Femur,  boy,  age  ten  years 187  IX 

Fracture  of  the  Lower  End  of  the  Humerus  with  Inward  Displacement  of  the  Lower 

Fragment,  boy,  age  ten  years 188  IX 

Normal  Foot,  child,  age  ten  years 195  IX 

Epiphysitis  of  the  Upper  Epiphysis  of  the  Tibia,  girl,  age  ten  years 199  IX 

Effusion  of  the  Knee-joint,  boy,  age  ten  years 206  IX 

Chronic  Osteomyelitis  of  the  Shaft  of  the  Femur,  child,  age  ten  years 211  IX 

Undetermined  Infection  of  the  Lower  Epiphysis  of  the  Tibia,  boy,  age  ten  years ....   230  IX 

TWELFTH  YEAR. 

Dislocation  and  Fracture  of  the  Anatomic  Head  of  the  Humerus,  boy,  age  eleven  years  181  IX 

Fracture  of  the  Astragalus,  boy,  age  eleven  years 193  IX 

Osteomyelitis  of  Fibula,  girl,  age  eleven  years 229  IX 

Syphilis  of  the  Lower  End  of  the  Humerus,  boy,  age  eleven  years 235  IX 

Normal  Hand,  Group  K,  girl,  age  eleven  and  one-fourth  years   38  II 

Normal  Hand,  Group  L,  girl,  age  eleven  and  three-fourth  years 39  II 

THIRTEENTH  YEAR. 

Normal  Child,  age  twelve  years 24  I 

Normal  Elbow,  child,  age  twelve  years 25  I 

Normal  Thorax,  cliild,  age  twelve  years 26  I 

Rhachitis  of  Adolescence — Hand,  child,  age  twelve  years 89  IV 

Osteomyelitis  of  Lower  Jaw,  colored  boy,  age  twelve  years 92  V 

Enlarged  Bronchial  Nodes,  girl,  age  twelve  years 109  VI 


XXIV  ILLUSTRATIONS. 

PLATK  DIV. 

Double  Pncumococcus  Lobar  Pneumonia,  boy,  age  twelve  years 112  VI 

Probable  Old  Tubercular  Process  of  the  Lung,  child,  age  twelve  years 122  VI 

Acute  Mihary  Tuberculosis  of  Both  Lungs,  girl,  age  twelve  years 124  VI 

Pericardial  Effusion,  child,  age  twelve  years 133  VI 

Enlarged  Heart  with  Pericardial  Effusion,  child,  age  twelve  years 134  VI 

Aneurism,  boy,  age  twelve  years 136  VI 

Abdominal  Ascites,  girl,  age  twelve  years 141  VII 

Nail  in  Right  Lung,  boy,  age  twelve  years 147  VIII 

Hsematoma  of  Heel,  child,  age  twelve  years 162  IX 

Medullary  Sarcoma  of  the  Lower  Part  of  the  Femur,  boy,  age  twelve  years 164  IX 

Exostosis  of  Astragalus,  boy,  age  twelve  years 171  IX 

Exostosis  of  the  Tibia,  boy,  age  twelve  years 175  IX 

Backward  Displacement  of  the  Inner  Condyle  of  the  Femur,  boy,  age  twelve  years  .   179  IX 

Fracture  of  the  Neck  of  the  Humerus,  boy,  age  twelve  years 182  IX 

Green-stick  Fracture  of  the  Radias,  girl,  age  twelve  years 189  IX 

Fracture  of  Tibia  with  Compensatory  Growth  of  Fibula,  girl,  age  twelve  years 196  IX 

Villous  Arthritis,  girl,  ago  twelve  years 201  IX 

Osteomyelitis  of  Lower  End  of  Tibia,  boy,  age  twelve  years 225  IX 

Osteomyehtis  of  the  Upper  End  of  the  Left  Tibia,  boy,  age  twelve  years 227  IX 

Early  Stage  of  Osteomyelitis  of  the  Lower  Extremity  of  the  Tibia,  boy,  age  twelve 

years 228  IX 

Atrophic  Condition  of  Hands,  boy,  age  twelve  years 232  IX 

Syphilis  of  Lower  End  of  Tibia,  girl,  age  twelve  years 241  IX 

Infection  of  Metatarsal  Bone,  girl,  age  twelve  years 242  IX 

Atrophy  of  Knee  from  Disuse,  girl,  age  twelve  years 243  IX 

Tuberculosis  of  the  Femur  and  Acetabulum,  boy,  age  twelve  years 250  IX 

Acute  Tubercular  Infection  of  the  Os  Calcis,  boy,  age  twelve  years 263  IX 

Double  Congenital  Dislocation  of  the  Hip,  girl,  age  twelve  and  one-half  years 59  III 

FOURTEENTH  YEAR. 

Right  Side  of  Head,  boy,  age  thirteen  years 27  I 

Retarded  Development  of  the  Pisiform  Bone  and  General  Anomalous  Condition, 

child,  age  thirteen  years 67  III 

Rhachitis  of  Adolescence,  Normal  and  Rhachitic  Hands,  boys,  age  thirteen  years. . .     88  IV 

Fracture  of  Skull,  boy,  age  thirteen  years 90  V 

Anomalous  Bicuspids,  Left  Side  of  Head,  boy,  age  thirteen  years 03  V 

Anomalous  Lower  Bicuspid,  Right  Side  of  Head,  boy,  age  thirteen  years 94  V 

Stone  in  Urethra,  Encapsulating  a  Pin,  girl,  age  thirteen  years 143  VIII 

Premature  Ossification  of  the  Lower  Epiphysis  of  the  Radius,  child,  age  thirteen  years  158  IX 

Extreme  Atrophy,  boy,  age  thirteen  years 166  IX 

Moderate  Flat-foot,  girl,  age  thirteen  years 178  IX 

Ankylosis  of  Ivnee-joint,  boy,  age  thirteen  years 202  IX 

Normal  Hand,  Group  M,  girl,  age  thirteen  and  one-half  years 40  II 

Chondrodystrophia  Foetalis,  boy,  age  thirteen  and  one-half  years 66  III 

FIFTEENTH  YEAR. 

Supernumerary  Tooth,  Right  Side  of  Head,  girl,  age  fourteen  years 97  V 

Supernumerary  Tooth,  Left  Side  of  Head,  girl,  age  fourteen  years 98  V 

The  End  Result  of  an  Old  Tubercular  Process,  child,  age  fourteen  years 252  EX 


ILLUSTRATIONS.  xxv 
SIXTEENTH  YEAR. 

PLATB  DIV. 

Supernumerary  Tooth,  Left  Side  of  Head,  boy,  age  thirteen  years 96  V 

EXACT  AGES  UNKNOWN. 

Examples  of  Comparative  Density Introductjon 

Roentgenograph  of  a  Congenital  Deformity  of  the  Foot 55  III 

Various  Anomalous  Conditions  Connected  with  the  Teeth  (some  of  the  ages  are  given 

in  legend) 99  V 

Tuberculosis  of  the  Spine,  Ilium  and  Left  Hip 102  V 

Tuberculosis  of  the  Ilium 103  V 

Tubercular  Abscess  of  the  Spine 104  V 

Transposition  of  Organs — Tuberculosis  of  the  Lungs  and  Bronchial  Nodes 110  VI 

Pericardial  Effusion  and  Obliteration  of  the  Cardiohepatic  Angle 135  VI 

Calcified  Mesenteric  Nodes 142  VII 

Foreign  Body  in  (Esophagus 145  VIII 

Penny  in  the  Descending  Colon 151  VIII 

Needle  in  the  Knee-joint 152  VIII 

Needle  in  the  Knee-joint.     Same  subject  as  Plate  152,  different  position 153  VIII 

Needle  in  the  Foot 154  VIII 

Needle  in  the  Foot.     Same  subject  as  Plate  154,  different  position 155  Vlll 

Needle  in  the  Tissues  Around  the  Phalanx  of  the  Little  Toe 156  VIII 

Early  Ossification  of  the  Upper  Epiphysis  of  the  Tibia 160  IX 

Subperiosteal  Hemorrhage  of  the  Left  Leg 170  IX 

Exostosis  of  the  Lower  Part  of  the  Femur 174  IX 

Fracture  and  Displacement  of  the  Head  of  the  Humerus 180  IX 

Old  Fracture  of  Tibia  and  Fibula  with  Connecting  Bridge 194  IX 

Rheumatic   Fever — Knee-joint 208  IX 

Rheumatic  Fever — Ankle-joint 209  IX 

Osteomyelitis  of  Lower  Arm 219  IX 


LIVING   ANATOMY   AND 
PATHOLOGY 

THE  DIAGNOSIS  OF  DISEASES 

IN 

EARLY  LIFE 

BY  THE 

ROENTGEN   METHOD 


Introduction 

In  a  clinical  text-book  very  little  space  should  be  given  to  de- 
scriptions of  apparatus  and  to  technic.  These  details  should  be 
acquired  from  books  written  for  this  purpose.  The  general  principles 
should  of  course  be  understood,  just  as  are  the  physics  of  ausculta- 
tion and  percussion  or  the  principles  of  the  ophthalmoscope  and 
of  the  electric  battery.  In  using  these  methods  of  investigation  we  do 
not  attempt  to  remember  all  the  mechanical  details,  but  begin  at  once 
to  obtain  clinical  information  from  them.  To  read  intelligently  and 
understand  what  is  shown  to  us  by  a  Roentgenograph  it  is  important 
that  we  should  first  have  mastered  a  knowledge  of  the  appear- 
ance of  the  gross  anatomic  and  pathologic  conditions  as  shown  by 
post-mortem  examinations.  We  can  then  use  the  knowledge  ac- 
quired in  this  way  to  compare  it  with  the  same  conditions  as  shown 
by  the  Roentgen  method  in  the  living  subject.  The  purpose  of  this 
book  is  to  teach  exactly  what  is  seen  by  the  student  when  he  examines 
a  Roentgen  plate  or  a  print  developed  from  it,  and  to  depend  on  his 
own  eye  to  interpret  the  conditions  presented  to  him.  In  reading 
through  another's  eye  the  effort  for  original  observation  is  diminished 
and  the  value  of  the  knowledge  thus  obtained  is  reduced  to  the 
level  of  a  diagram,  being  of  about  as  much  value  for  teaching  as  is 

a  diagram  in  a  book  in  comparison  with  what  is  taught  to  the  student 

1 


2  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

by  the  use  of  the  stethoscope.  The  difference  in  the  methods  of 
acquiring  information  on  the  one  hand  from  hearing  and  touch  and 
on  the  other  from  sight  is  that  in  the  former  case  the  expert  instructor 
stands  beside  the  student  and  educates  his  ear  by  telHng  him  what 
he  hears.  On  the  contrary,  by  the  Roentgen  method  the  expert 
interpreter  need  not  necessarily  be  present,  but  can  be  replaced  by 
an  expert  explanation  in  a  book,  provided  that  such  explanation 
describes  accurately  what  the  Roentgenograph  shows.  The  personal 
element  should  in  fact  be  eliminated  as  much  as  possible,  because  we 
all  know  how  mistaken  we  may  be  and  what  different  opinions  are 
given  in  regard  to  what  is  heard  and  felt  by  different  individuals. 
On  the  contrary,  the  eye  does  not  err  to  the  same  extent.  A  number 
of  pathologists  do  not  differ  so  much  in  an  opinion  as  to  what  they 
actually  see  in  a  liver  at  the  postmortem  as  do  a  number  of  clinical 
experts  as  to  what  they  hear  in  the  lung  or  feel  in  the  abdomen  during 
life.  This  is  because  our  senses  of  hearing  and  of  touch  are  not  con- 
stant, while,  on  the  contrary,  a  photograph  of  the  object  is  constant 
and  gives  rehable  information.  The  Roentgenograph  gives  an  actual 
picture  of  the  lung,  heart,  and  other  organs  ante  mortem,  just  as 
the  photograph  of  the  liver,  lung,  or  heart  gives  such  accurate  infor- 
mation post  mortem.  In  either  case  the  personal  element  is  elimi- 
nated and  the  text  can  describe  what  a  number  of  expert  Roentgen- 
ologists can  commonly  agree  to  be  present  in  the  picture,  just  as  a 
number  of  pathologists  can  agree  in  examining  an  organ  at  the 
autopsy.  As  to  how  much  error  occurs  in  and  what  can  or  cannot 
be  seen  in  a  special  Roentgenograph  will  be  explained  later.  It  is 
fair  to  assume,  however,  always  allowing  that  Roentgenology  is  in 
its  infancy,  and  also  that  we  cannot  at  present  always  read  what  is 
seen  in  the  plate,  that  the  picture  as  shown  is  true.  Misconceptions 
may  arise  from  a  distortion  of  the  angle  at  which  the  picture  is  taken, 
or  from  some  faulty  technic,  or  from  lack  of  training  in  the  interpre- 


INTRODUCTION.  3 

tation  of  what  the  eye  is  actually  looking  at.  All  these  obstacles  to  a 
correct  diagnosis  will  in  the  future  gradually  disappear  as  progress  is 
made  in  perfecting  the  electrical  machine  and  when  practitioners  be- 
come as  expert  in  the  use  of  the  plate  or  Roentgenograph  as  they 
are  now  in  the  use  of  the  laryngoscope  and  of  the  ophthalmoscope. 
In  order  to  obtain  the  most  exact  knowledge  of  disease,  every  prac- 
titioner of  medicine  and  surgery  should  be  taught  what  the  Roent- 
gen method  is,  and  should  have  at  his  command  pictures  which  can 
be  readily  explained.  These  explanations  can  be  accomplished  by  a 
description  in  the  text  of  the  illustrations,  aided  by  leaders  desig- 
nating the  important  details.  These  if  closely  studied  will  make 
the  diagnosis  for  the  observer  and  will  be  of  incalculable  aid  in 
treatment. 

Our  knowledge  of  both  the  normal  and  pathologic  anatomy  of 
human  beings  has  heretofore  depended  almost  entirely  on  the  post- 
mortem findings.  These  findings,  although  of  great  use,  especially 
under  abnormal  conditions,  have  never  been  so  complete  as  is  desira- 
ble when  the  different  stages  of  development  are  under  consideration. 
Still  greater  difficulties  arise  when  we  attempt  to  determine  the 
primary  pathology  of  the  various  diseases.  In  many  instances  we  are 
dealing  only  with  results  which  may  represent  the  terminal  lesions 
of  a  number  of  diseases,  and  yet  fail  to  give  us  the  early  and  char- 
acteristic lesions  of  the  especial  disease.  In  other  words,  it  is 
important  to  obtain  an  exact  knowledge  of  the  living  patholog}'^  of 
the  part  affected  from  the  time  of  the  earliest  deviation  from  the 
normal  which  it  is  possible  to  recognize,  as  the  dead  pathologic 
conditions  may  only  give  end  results,  and  may  be  end  results 
common  to  a  number  of  different  infections.  Any  means  by 
which  we  may  recognize  a  disease  in  its  early  stages,  whether  it 
be  an  effusion  in  the  pericardium  or  in  the  pleura,  or  obscure 
centres  of  pulmonary  solidification,  or  an  osteomyelitis,  or  a  clin- 


4  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

ically  hidden  fracture,  is  of  extreme  value,  and  indeed  a  neces- 
sity according  to  our  modern  ideas  of  diagnosis  for  treatment. 
This  means,  more  or  less  perfected,  has  been  given  to  us  by  the 
Roentgen  method,  and  the  knowledge  derived  from  this  method, 
teaching  us  the  actual  living  conditions,  is  becoming  more  and 
more  extensive  and  exact.  The  constant  study  of  children  in  health 
and  in  disease  by  the  use  of  the  Roentgen  method  will  give  us 
information  of  a  large  part  of  living  normal  and  pathologic  anatomy. 
This  will  enable  us  to  judge  of  a  diseased  lung  or  other  organ  ante 
mortem,  while  prior  to  the  discovery  of  the  Roentgen  ray  we  could 
only  obtain  our  information  from  the  findings  of  a  post-mortem 
examination.  It  is  therefore  important  that  the  results  of  the  studies 
which  have  been  made  of  a  great  variety  of  pathologic  conditions 
by  means  of  the  Roentgen  ray  should  be  recorded  and  reported  to 
the  student  of  medicine  in  conjunction  with  his  other  medical  studies. 
The  Roentgen  method  in  the  practice  of  medicine  assists  rather  than 
replaces  any  of  the  known  means  of  diagnosis.  It  has  opened  up  a 
new  field  in  the  study  of  health  and  of  disease  in  both  normal  and 
pathologic  conditions.  It  is  not  confined  to  the  bones,  but  is 
applicable  to  all  conditions  of  the  tissues  which  from  their  histologic 
nature  may  be  differentiated  by  the  Roentgen  ray. 

As  is  well  known,  there  are  two  methods  of  obtaining  informa- 
tion concerning  the  living  normal  and  living  pathologic  conditions 
by  means  of  the  Roentgen  ray.  One  is  by  the  use  of  the  fluoroscope 
and  the  other  by  the  Roentgen  plate.  Each  has  its  own  advantages 
for  diagnostic  purposes.  It  is  as  useless,  impractical,  and  narrow 
to  praise  one  at  the  expense  of  the  other,  as  it  would  be  to  discuss 
the  individual  merits  of  auscultation  and  percussion  from  the  point 
of  view  that  one  should  be  used  rather  than  the  other.  In  one  case, 
as  in  the  other,  it  is  the  use  of  both  methods  which  alone  can  give 
all  the  information  ascertainable  in  health  and  in  disease.     There 


INTRODUCTION.  5 

is  no  doubt  that  the  fluoroscope  in  the  hands  of  an  expert  will  give 
especially  valuable  information  of  the  part  examined.  The  expan- 
sion and  contraction  of  the  lungs,  the  rise  and  fall  of  the  diaphragm, 
and  the  expansion  and  contraction  of  the  muscles  of  the  heart  can 
by  this  method  be  actually  seen  and  studied,  as  can  also  the  peristalsis 
of  the  stomach  and  of  the  intestines.  By  this  method  we  can  deter- 
mine the  normal  excursions  of  the  diaphragm  as  differing  on  one 
side  from  the  other,  and  the  greater  or  less  distention  of  the  lungs. 
We  can  thus  also  establish  a  standard  which  can  be  accepted  as 
within  the  limits  of  normal  variation  according  to  the  stage  of  devel- 
opment of  the  individual.  In  this  way  the  trained  eye  is  enabled 
to  recognize  the  normal,  to  detect  the  abnormal,  and  to  see  the  hving 
rhythmic  movements  of  the  heart,  the  lungs,  and  the  diaphragm. 
Bearing  the  normal  standard  in  mind,  and  recognizing  a  greater  or 
less  excursion  of  the  diaphragm,  according  to  the  greater  or  less 
expansion  of  the  lung,  we  can  decide  whether  we  are  looking  at  a 
normal  or  abnormal  diaphragmatic  excursion.  If  abnormal,  and 
knowing  that  the  lungs  when  over-distended  show  a  greater  radia- 
bility,  and  that  when  the  pulmonary  tissue  is  denser,  or  when  the 
alveoli  contain  an  exudate,  they  show  a  lessened  radiabiUty,  we  can 
infer  that  areas  of  disease  are  present.  Also  that  in  over-expansion 
we  should  suspect  emphysema,  while  in  deficient  expansion  we 
should  infer  a  condition  of  atelectasis  or  of  solidification.  In  this 
connection  the  use  of  the  fluoroscope  is  of  the  greatest  importance 
in  the  diagnosis  of  such  conditions,  as  for  instance  an  early  tuber- 
culosis. The  other  side  of  the  question  in  regard  to  the  fluoroscopic 
method  is  that  the  sense  of  sight  may  vary,  although  not  so  much 
as  does  that  of  touch  and  of  sound.  Even  experts  may  differ  in  an 
opinion  as  to  what  they  see,  just  as  experts  in  the  use  of  the  stetho- 
scope and  pleximeter  may  differ  as  to  what  they  hear  or  feel.  It  is 
also  true  that  a  good  Roentgen  plate  tells  the  truth  and  records  it 


6  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

accurately.  The  plate  may  be  poor  and  difficult  to  read,  but  if  we 
grant  a  good  fluoroscopic  expert  we  must  also  grant  an  excellent 
plate.  Such  an  expert,  however,  with  the  ever  moving  image  of 
the  picture,  which  he  can  simply  describe  and  not  record  except  in 
tracings  made  by  his  own  hand,  orthodiagraphic  or  otherwise,  is 
invaluable  on  account  of  his  skilled  observation.  The  Roentgen 
plate  and  the  record  which  it  makes  is  absolute  and  can  be 
referred  to,  studied,  and  discussed  by  any  number  of  observers. 
There  is  no  error  in  the  plate  due  to  a  personal  equation  or  to  tem- 
perament. It  can  be  studied  as  are  photographs  of  the  moon,  which 
are  far  more  valuable  for  exact  rudimentary  teaching  than  what 
can  be  seen  through  the  telescope.  When,  moreover,  the  question 
arises  of  illustration  in  a  book  for  the  purpose  of  teaching  the  Roent- 
gen method,  for  the  elucidation  of  diseases  of  all  parts  and  organs, 
it  is  evident  that  the  plate  should  be  used. 

To  take  a  Roentgenograph  successfully  a  number  of  points  are 
essential.  A  great  deal  depends  upon  the  personahty  and  knowledge 
of  the  operator  and  interpreter,  and  in  the  case  of  children  on  his 
patience  and  personal  influence.  The  operator  should  have  mechani- 
cal skill  and  great  intelligence  in  making  use  of  that  skill.  As  an 
interpreter  he  should  be  as  little  as  possible  influenced  by  individual 
personalit3^  He  should  also  have  an  intimate  knowledge  of  the 
pathologic  conditions  which  have  been  studied  and  recognized  as 
representing  the  various  diseases  as  they  appear  post  mortem.  It 
is  of  course  presupposed  that  he  has  also  a  thorough  and  detailed 
knowledge  of  the  conditions  which  represent  living  normal  anatomy 
at  different  periods  of  its  development.  In  fact  he  should  be  both 
an  anatomist  and  a  pathologist.  The  degree  to  which  pathologic 
conditions  can  be  recognized  in  the  Roentgenograph  depends  upon 
what  can  be  demonstrated  on  the  Roentgen  plate.  It  is  the  grosser 
pathology   which    can   be   best   recognized   in   the   interpretation, 


INTRODUCTION.  7 

since  the  finer  pathologic  conditions  shown  by  a  microscope  will 
not  produce  efifects  which  can  be  differentiated  by  the  eye.  The 
Roentgen  picture  is  obtained  by  the  greater  or  less  atomic  weight 
of  the  tissue  which  the  ray  penetrates,  as  shown  by  the  greater  or 
less  obstruction  of  the  ray.  For  instance,  if  the  radiability  is 
great,  as  in  the  case  of  normal  lung  tissue,  the  dark  surface  of  the 
plate  is  shown,  while  the  neighboring  vertebrae  and  ribs,  owing  to 
their  increased  density,  obstruct  the  passage  of  the  ray  and  are 
shown  on  the  plate  as  white.  When  a  print  is  taken  from  such  a 
plate  the  reverse  of  this  result  takes  place,  the  lung  becoming  Ught 
and  the  bone  dark,  and  the  right  in  the  plate  becoming  the 
left  in  the  print.  What  the  student  must  remember,  therefore, 
in  considering  the  pictures  on  the  plate,  is  that  the  greater  the  atomic 
weight  of  the  object  the  greater  is  the  density  and  the  less  the  radia- 
bility; also  that  the  nearer  the  object  is  brought  to  the  plate  the 
more  precise  and  less  distorted  is  the  picture.  Thus,  to  take  the  two 
extremes,  if  a  cavity  is  filled  with  air  the  effect  produced  on  the 
plate  is  practically  nil,  while  if  the  cavity  is  filled  with  water  the 
resulting  picture  is  lighter  according  to  the  greater  depth  of  the 
cavity.  The  student  should  therefore  remember  what  radiabiUty 
means,  and  appreciate  that  innumerable  degrees  of  light  or  dark 
effects  can  be  left  on  the  plate  corresponding  to  the  innumerable 
degrees  of  density  resulting  from  a  difference  in  the  atomic  weights. 
When  the  student  has  mastered  this  idea  he  will  learn  to  recognize 
first  the  radiability  of  normal  tissue,  for  instance,  what  the  picture 
of  the  normal  lung  with  its  great  radiability  should  be,  and  then 
what  is  seen  in  a  diseased  lung  when  the  radiability  is  decreased. 
Again,  in  reading  the  picture  produced  on  the  plate  in  abnormal 
conditions  of  the  abdominal  cavity,  he  must  bear  in  mind  that  the 
greater  the  amount  of  fluid  the  less  is  the  radiabihty  and  the  lighter 
the  resulting  effect.    He  must  also  note  the  greatly  lessened  radiabil- 


8  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

ity  in  the  region  of  the  hver,  spleen,  or  kidney,  and  the  abnormal  size 
and  density  of  the  picture  produced  by  an  enlarged  liver,  spleen, 
kidney,  or  abnormal  object  such  as  a  gall-stone,  a  renal  calculus, 
or  a  foreign  body.  It  should  of  course  be  understood  that  the 
picture  on  the  plate  may  not  necessarily  be  uniformly  clear.  On 
the  other  hand,  a  clear  picture  of  a  part  may  be  obtained  by  skil- 
fully concentrating  the  ray  on  that  part.  It  should  also  be  under- 
stood that  the  print  from  the  plate  is  never  so  clearly  defined  as 
is  the  original  picture  on  the  plate  itself,  even  in  the  hands  of  one 
whose  technic  is  excellent.  It,  therefore,  becomes  merely  a  question 
of  improved  technic  and  perfected  reproduction.  What  we  wish  to 
teach  the  student  is  to  cultivate  his  powers  of  observation  and  to 
recognize  what  the  illustration  shows.  This  can  be  done  by  means 
of  leaders  indicating  the  especial  parts  or  details  of  the  parts  ex- 
plained in  the  text.  It  is  evident  that  a  very  close  and  extended 
study  of  Roentgen  plates  in  general  should  be  made,  in  order  to 
recognize  the  innumerable  differences  presented  to  the  eye  by  a 
Roentgen  illustration. 

The  different  tissues  of  the  body  are  made  up  of  different  ele- 
ments, such  as  nitrogen,  oxj^gen,  calcium,  phosphorus,  and  many 
others,  each  of  which  has  its  own  atomic  weight.  We  can  therefore 
anticipate  what  the  radiability  of  a  given  tissue,  such  as  fat,  muscle, 
and  bone,  will  be,  according  as  we  know  of  what  elements  it  is  com- 
posed. Knowing  the  atomic  weights  of  these  elements  we  can  then 
deduce  that  there  will  be  a  greater  or  less  radiabihty.  Thus  where 
calcium  is  present,  as  in  the  bones,  its  high  atomic  weight  (40)  would 
produce  a  lessened  radiability,  while  water,  with  its  low  atomic 
weight  of  hydrogen  and  oxygen,  would  allow  of  a  high  degree  of 
radiability.  Again,  where  much  air  is  present  in  the  medium  through 
which  the  ray  has  to  penetrate,  the  obstruction  is  almost  nil.  The 
radiabihty  of  air  is  so  great  that  in  the  Roentgen  plate  there  is  a 


PLATE   1. 

EXAMPLES  OF  COMPARATIVE  DENSITY. 

Fig.  1.  Roentgenograph  of  the  Shaft  of  a  Long  Bone. 
.1 .  Cortex. 
B.   Medulla. 

Fig.  2.  Thk  Diaphyses  of  a  Tibia  and  a  Fibula. 

A.  Cortex  of  the  tibia. 

B.  Cortex  of  the  fibula. 

C.  Area   of    increa.sed    density   from  one  bone  over- 

lapping the  other. 

Fig.  3.   Diaphvsis  and  Epiphysis  of  the  Tibia  and  Fibula  and 
THK  SiPEUioK  Surface  of  the  .\stragalus. 
.1.    Diaphj'sis  of  the  tibia. 

B.  Diaphy.sis  of  the  fibula. 

C .  Zone  of  proliferation. 

D.  Epiphysi.s  of  the  tibia. 

E.  Epiphysi.s  of  the  fibula. 

F.  Astragalus. 
H.  Cartilage. 

/.    Dark-   area  from  overlapping   of   tlie  diaphyses  of 

the  tibia  and  of  tlie  fibula. 
J.   Dark  area   from  overlapping  of  the  diaphysis  of 

the  fibula  and  the  epiphysis  of  the  tibia. 
K.   Region  of  the  cap.sule  of  the  joint. 

Fig.  4.  Heel  of  Foot. 

-4.   United  epiphvsis  of  os  calcis. 

B.  Fat. 

C.  Space  occupied  b\-  cartilage  between  os  calcis  and 

cuboid. 

D.  Plantar  fascia. 

Fig.  5.  Comparison  of  Fat  and  Muscle. 
.4.  Fat. 
B.  Muscle. 

Fig.  6.  Comparison  of  Fat,  .Muscle,  and  Bone. 
.1.   Fat. 

B.  Muscle. 

C.  Outline  of  bone. 

(All  these  figures  are  taken  from  different  plates.) 


FIG.  1. 


Plate  1 


FIG.  2. 


FIG.  5. 


FIG.  3. 


FIG.  6. 


FIG.  4. 


M 

■■ 

■ 

■ 

^^V> 

w 

^ 

9 

r 

I  < 

* 

> 

A 

B 

.^i^ 

INTRODUCTION.  9 

very  marked  difference  in  the  effect  produced  between,  for  instance, 
an  emphysematous  lung  and  an  abdominal  ascites.  Of  course,  when 
tissues  through  which  the  ray  passes  have  a  low  atomic  weight,  the 
radiabihty  differs  according  to  the  number  of  layers  of  such  tissues, 
or  in  other  words  the  denser  the  tissue  the  less  the  radiability.  The 
atomic  weight  of  blood  and  that  of  water  being  so  nearly  alike, 
there  is  no  great  difference  in  their  radiabihty.  In  order  to  explain 
diagrammatically  what  has  just  been  said,  I  have  shown  in  Plate  1 
the  different  degrees  of  radiability  of  different  tissues  and  of  the 
same  tissue. 

Plate  No.  9  (Div.  I)  shows  the  comparative  radiability  of  the 
lung,  heart,  spine,  liver,  intestine,  and  stomach. 

The  illustrations  in  Plates  1  and  9  emphasize  that  no  one 
definite  picture  can  be  taken  as  a  standard  of  one  especial  tissue, 
since  the  pictures  of  any  of  the  tissues  may  differ  considerably. 
This  is  shown  in  the  difference  of  the  radiability  of  the  cancellous 
tissue  in  Plate  1,  Figs.  2  and  3,  leader  A,  and  the  muscle  in  Figs.  5 
and  6,  leader  B.  All  the  reproductions  in  Plate  1  are  taken  from 
different  prints. 

It  must  be  understood  therefore  that  the  greater  or  less  apparent 
radiabihty  of  an  organ  on  one  plate,  for  instance,  of  the  effect  pro- 
duced by  a  heart,  may  differ  greatly  from  the  apparent  radiabihty 
of  a  heart  on  another  plate,  since  the  degree  of  radiabihty  is 
determined  by  comparing  it  with  the  liver,  lung,  bones,  and  tissues 
on  its  own  plate.  Following  from  this  the  student  must  understand 
that  there  is  no  one  especial  degree  of  density  which  he  is  to  expect 
to  find  in  an  individual  plate.  The  radiability  as  shown  in  Plate  1 
represents  what  can  be  seen  in  a  Roentgenograph,  and  in  no  way 
presupposes  that  the  degree  of  density  shown  in  these  examples  will 
always  necessarily  appear  when  the  student  is  examining  a  plate  for 
diagnosis.    In  other  words,  all  the  knowledge  which  is  derived  from 


10  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

a  Roentgen  plate  rests  on  a  basis  of  comparison.  The  student  must 
also  understand  when  he  is  examining  a  print  from  a  Roentgen  plate 
that  he  should  consider  on  which  side  of  the  part  taken  is  the  plate 
and  that  he  is  supposed  to  be  looking  through  the  plate  at  the  part. 
He  must,  for  instance,  remember  when  he  is  looking  at  the  trunk 
that  he  is  looking  at  the  indi^^dual  from  behind  when  the  indi^'idual 
has  his  back  on  the  plate.  He  must  also  remember,  from  our  knowl- 
edge of  the  chemistry  of  the  reproductive  process,  that,  while  the 
greater  radiability  of  the  lung  tissue  shows  dark  on  the  plate,  it  will 
show  light  on  the  print.  In  like  manner,  therefore,  all  Ught  effects 
in  the  plate,  such  as  of  bone,  heart,  or  liver,  will  show  dark  in  the 
print. 

Like  many  other  means  for  diagnosis  where  the  technic  is  diffi- 
cult, discredit  has  been  thrown  upon  the  value  of  diagnosis  by  the 
Roentgen  method.  This  discredit  comes  from  a  number  of  causes. 
First,  the  technic  is  difficult  to  acquire,  and  often  has  to  be  accom- 
plished by  means  of  imperfect  apparatus.  Again,  a  systematic 
method  of  studjang  the  plate,  and  thus  interpreting  what  such  a 
plate  should  show,  is  usually  not  employed.  We  must  also  under- 
stand that  we  often  cannot  expect  to  have  as  clear  a  picture  in  disease 
as  in  health.  Given  the  same  apparatus  and  the  same  skill  in  taking 
the  pictures,  the  very  indefiniteness  of  surface  and  of  outhne  makes 
us  suspect  a  diseased  condition  on  comparing  the  picture  with  the 
same  parts  in  their  normal  condition.  In  disease  the  greater  or  less 
atomic  weight  of  the  lungs  and  of  fluids  in  the  pericardium  or  pleura 
may  throw  a  haziness  over  the  whole  picture  and  may  obscure  ana- 
tomic details  which  under  normal  conditions  are  verj^  evident.  This 
very  haziness  to  the  eye  of  the  skilled  interpreter  becomes  a  definite 
entity  and  determines  the  diagnosis. 

Different  Roentgenologists  prefer  different  positions  of  the 
subject  to  be  taken.     The  plate  placed  against  the  back  or  front 


INTRODUCTION.  11 

naturally  produces  pictures  which,  according  to  whether  the  parts 
are  nearer  or  farther  away  from  the  plate,  show  more  or  less  dis- 
tinctly. In  taking  the  illustrations  used  in  this  book  we  have  chosen 
for  our  routine  position  the  subject's  back  directly  against  the  plate. 
In  this  position  we  do  not  get  the  picture  of  the  sternum  and  front 
of  the  ribs;  these  we  take  with  the  subject  on  the  side,  since  pictures 
of  the  sternum  taken  with  the  subject  on  its  face  are  unsatisfactorj^ 
owing  to  the  interposition  of  the  vertebrae.  Pictures  which  are 
taken  with  the  back  on  the  plate  show  what  would  be  seen  with  the 
front  part  of  the  thorax  removed,  that  is,  the  sternum,  ribs,  and 
cartilage  about  as  far  as  the  anterior  axillary  lines. 

It  is  the  faulty  technic  in  taking  a  Roentgenograph  which 
invalidates  accuracy,  and  a  satisfactorj^  interpretation  is  often  lost 
by  not  approaching  the  subject  in  a  systematic  manner,  such  as  we 
would  use  in  making  a  physical  examination  of  a  patient.  Before 
describing  a  uniform  method  for  examining  and  interpreting  the 
plate  it  is  necessary  to  understand  the  difference  between  a  photo- 
graph and  a  Roentgenograph.  The  photograph  of  an  object  shows 
in  its  negative  only  its  exterior,  which  is  reflected  on  the  camera  and 
on  the  eye,  gi\'ing  the  outline,  the  shape,  and  the  surface  markings. 
In  the  Roentgenograph,  the  plate  of  which  is  positive,  we  do  not  see 
the  exterior  of  the  object,  with  the  exception  of  its  outhne,  shape, 
and  prominences,  but  we  get  the  details  of  its  internal  or  general 
structure.  Therefore  in  order  to  interpret  Roentgenographs  correctly 
it  is  necessary  that  we  should  not  only  be  famiUar  with  the  external 
anatomy  of  the  part  to  be  examined  but  also  with  the  interior  struc- 
ture. In  studying  a  given  plate  certain  points  must  be  considered 
and  the  same  method  followed  as  employed  in  the  cUnical  diag- 
nosis of  the  lungs,  pleura,  and  heart.  In  the  examination  of  a  Roent- 
genograph in  reference  to  an  extremity  or  to  an  organ,  the  general 
location,  size,  shape,  and  position  should  always  be  considered  in 


12  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

comparison  with  what  is  known  of  such  part  or  parts.  For  instance, 
in  an  examination  of  the  thorax  a  variation  from  the  normal,  such 
as  a  deficiency  in  the  number  of  the  ribs,  or  a  variation  in  the  number 
on  one  side  in  comparison  with  the  other,  should  be  noted.  In  exam- 
ining an  extremity  the  general  outline  and  the  density  of  the  part 
in  question  should  be  considered.  Then  we  should  study  the  picture 
as  though  a  vertical  section  had  been  made  through  its  tissues,  and 
we  should  compare  such  section  with  the  section  of  what  would  be 
normal  at  the  same  stage  of  development.  For  example,  in  examin- 
ing the  Roentgenograph  of  a  leg  we  should  first  compare  the  appear- 
ance of  the  fat  tissue  with  what  would  normally  be  expected  in  the 
individual.  We  should  next  consider  the  muscle  as  to  its  atrophy 
or  hypertrophy  in  comparison  with  normal  muscle.  Next  we  should 
observe  whether  the  periosteum  can  be  seen  or  not,  knowing  that 
under  normal  conditions  it  is  not  seen,  and  that  if  abnormal  it 
may  come  into  view.  We  next  consider  the  cortical  substance  of 
the  bone  as  to  whether  in  comparison  with  the  normal  conditions 
of  the  cortex  at  the  same  period  of  development  it  is  narrower, 
indicating  atrophy,  or  broader,  indicating  hypertrophy.  We  should 
also  note  whether  it  shows  increased  radiabiUty,  indicating  absorp- 
tion of  the  lime  salts,  or  decreased  radiability,  showing  thickening 
and  greater  density.  Next  we  observe  the  medullary  canal  as 
to  whether  it  is  broader  or  narrower  than  under  normal  condi- 
tions, and  also  noticing  whether  it  is  replacing  the  cortex  of  the 
bone  or,  if  it  looks  smaller,  whether  it  is  being  encroached  upon  by 
an  internal  thickening  of  the  surrounding  cortex.  All  this  is  of  im- 
portance in  recognizing  abnormal  conditions,  such  as  contusions, 
abscesses,  atrophy  due  to  nerve  lesions  or  to  general  abnormal 
changes,  such  as  growths  or  the  presence  of  foreign  bodies. 

A  short  resume  of  what  has  been  stated  already  in  regara  to 
the  detailed  examination  of  a  Roentgenograph  may  be  of  use  to  the 
student. 


INTRODUCTION.  13 

1.  We  should  always  compare  the  part  of  the  individual  under 
observation  with  the  corresponding  part  of  the  same  individual. 
This  is  often  of  great  value  where  there  may  be  only  a  slight  devia- 
tion from  the  normal,  as  for  instance  in  an  arm  from  the  normal 
arm  on  the  other  side. 

2.  We  should  notice  not  only  any  change  in  the  size  but  in  the 
density,  and  any  abnormal  shape  which  may  be  present. 

3.  Subcutaneous  Tissue. — In  examining  the  subcutaneous  tissue 
we  should  note,  in  comparison  with  the  corresponding  opposite  side, 
its  density,  its  thickness,  and  its  shape. 

4.  Muscle. — In  examining  a  muscle  we  should  note  any  abnor- 
mahty  of  outline,  density,  thickness,  or  shape,  as  denoting  inflam- 
mation, abscess,  foreign  bodies,  or  new  growths. 

5.  Bone. — In  examining  a  bone  we  should  note  the  general 
outline,  comparing  the  age  of  the  individual  under  examination  with 
what  is  known  anatomically  of  a  given  part  in  regard  to  its  age  and 
size.  We  should  also  note  whether  the  periosteum  is  visible  or  not, 
and  whether  there  are  any  irregularities  such  as  might  be  caused 
not  only  by  changes  in  the  periosteum  but  also  by  exostoses.  By 
observation  and  experience,  therefore, 

A.  We  should  set  a  standard  for  ourselves  as  to  the  normal 

densities  of  the  bones  and  of  the  tissues; 

B.  We  should  then  recognize  a  condition  of  atrophy,  distin- 

guishing 

a.  Atrophy  from  disease; 

b.  Atrophy  from  disuse; 

c.  Atrophy  from  a  combination  of  both. 

C.  The  size  of  the  cortex  and  of  the  medullary  canal  and  their 

relations  to  each  other  should  be  considered. 
Certain  groups  of  diseases  in  early  Ufe,  such  as  diseases  of  nutri- 
tion, are  characterized  by  a  diminution  or  an  increase  in  surface  and 
outline,  and  by  a  greater  or  less  density  of  the  bone. 


14  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

In  examining  for  abnormal  conditions  of  the  cortex  we  shovild 
note  its  density  and  its  size  as  compared  with  the  medulla.  The 
examination  of  a  normal  bone  shows  a  uniform  definition  of  the 
cortex,  varying  according  to  the  density  and  size  of  the  special  part 
of  the  bone,  but  this  again  varies  in  different  bones.  For  instance, 
the  cortex  of  the  femur  at  the  upper  end  is  thinner  than  the  cortex  at 
the  middle  of  the  shaft.  A  knowledge  of  the  different  variations  in 
the  size  of  the  cortex  is  important.  It  will  not  vary,  however,  to 
any  great  extent  in  different  individuals.  In  certain  diseases,  such 
as  rhachitis,  osteomalacia,  and  osteogenesis  imperfecta,  the  density 
of  the  cortex  will  vary  from  that  of  the  normal  to  a  greater  or  less 
extent.  Thus  from  our  knowledge  of  the  normal  cortex  we  will  be 
able  to  tell  from  the  plate  that  there  is  a  change  in  or  a  disease  of 
the  bone.  It  is  important  to  compare  the  cortex  with  the  medullary 
canal,  since  in  certain  conditions  it  will  be  found  that  the  medulla 
increases  at  the  expense  of  the  cortex,  or  that  the  cortex  increases 
at  the  expense  of  the  medulla. 

In  examining  the  medullary  canal  we  should  note  its  density 
and  compare  it  with  the  cortex,  bearing  in  mind  what  should  be 
normal  in  the  individual  stage  of  development  present.  The  medul- 
lary canal  can  be  demonstrated  very  definitely  by  the  Roentgen 
method.  It  varies  in  density  and  in  width  in  the  different  bones 
and  parts  of  bones,  and  here  again  is  impressed  upon  us  the  impor- 
tance of  knowing  how  each  bone  of  the  skeleton  looks  at  different 
periods  of  development.  This  leads  to  the  differentiation  between 
atrophy  of  size  of  the  bone  and  atrophy  from  a  change  in  its  quality 
or  from  osteoporosis. 

We  should  also  examine  the  strttcfure  of  the  bone,  observing 
whether  there  is  anything  abnonnal  in  connection  with  its  cancellous 
tissue  or  with  its  trabeculae.  It  is  in  the  differentiation  of  the  differ- 
ent structures  above  mentioned  that  the  Roentgen  ray  is  able  to 


INTRODUCTION.  15 

detect  disease.  A  knowledge  of  the  structure  of  a  given  bone  of  the 
skeleton  at  different  stages  of  its  development  will,  in  connection  with 
the  other  points  just  mentioned,  lead  to  an  understanding  of  the 
early  changes  in  a  part  or  in  the  whole  of  the  bone.  In  certain 
infectious  processes  of  the  bone-marrow,  where  there  is  an  infil- 
tration or  an  abscess,  the  normal  structure  of  the  bone  will  be  seen  to 
be  destroyed  or  to  be  replaced  by  foreign  material.  Again  in  diseases 
such  as  rhachitis  the  structure  of  the  bones  will  be  seen  to  adapt 
itself  to  abnormal  changes  so  as  to  compensate  for  the  superincum- 
bent weight. 

6.  Periosteum. — The  periosteum  in  a  normal  bone  is  not  seen, 
and  it  becomes  apparent  only  when  there  is  an  exudate  beneath  it, 
or  when  it  is  inflamed  or  thickened. 

7.  Epiphyseal  Line  or  Zone  of  Proliferation. — We  should  examine 
the  epiphyseal  Une  or  zone  of  proUferation  with  great  care,  because 
it  is  by  a  knowledge  of  its  normal  appearance  that  sUght  changes, 
such  as  from  infection,  from  disturbance  of  nutrition,  from  trauma, 
from  epiphyseal  dislocations,  from  fractures,  and  from  many  changes 
that  may  affect  its  uniformity  are  revealed  by  the  Roentgen  method. 
Fractures  should  be  looked  for,  whether  partial  or  complete.  The 
attachment  of  the  tendons,  as  represented  bj^  depressions  or  prom- 
inences, should  be  noticed.  Spur  formation  or  h3'pertrophic  osteo- 
phytes should  be  recognized.  No  two  bones  of  the  same  part  will 
show  the  same  outhne,  but  it  is  the  knowledge  of  the  normal  and 
the  variation  from  the  normal  which  makes  the  interpretation  of  a 
slight  degree  of  irregularity  from  disease  possible. 

8.  Epiphyses. — It  should  be  noted  whether  the  epiphyses  of 
the  various  bones  have  appeared,  their  size,  and  their  condition. 

9.  The  centres  of  ossification  should  he  carefully  noted. 

We  should  always  bear  in  mind  that  what  would  be  normal  for 
one  period  of  development  may  be  abnormal  for  another.    Therefore 


16  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

a  knowledge  of  the  different  stages  of  development  is  of  the 
greatest  importance  in  determining  whether  disease  is  present  or 
not.  We  must  admit  that  we  are  studying  histology  and  pathology 
in  its  most  important  aspect,  that  is,  under  living  conditions,  and 
that  a  knowledge  of  these  conditions  is  exceedingly  valuable  not 
only  for  diagnosis  but  for  treatment.  We  must  remember  that 
although  the  knowledge  we  obtain  from  the  microscope  is  of  very 
great  value,  yet  at  times  macroscopic  are  as  useful  as  micro- 
scopic pictures.  A  magnifying  glass  is  of  great  use  in  studying 
reproductions  from  Roentgenographs. 


Division  I 

LIVING  NORMAL  ANATOMY 

A  THOROUGH  knowledge  of  living  normal  anatomic  conditions 
should  be  acquired  before  we  can  understand  what  we  see  in  living 
pathologic  conditions  and  recognize  the  lesions  of  the  various  diseases 
during  life.  This  would  be  comparatively  simple  if  we  could  merely 
study  the  normal  living  anatomy  of  the  fully  developed  adult,  and 
of  course  such  study  is  necessary  and  is  very  important.  This  Uving, 
fully  developed  anatomy  of  adults,  however,  is  only  one  link  of 
the  much  more  extensive  and  complicated  chain  of  evidence  which 
enables  us  to  diagnosticate  normal  anatomic  conditions  through 
all  their  stages  of  development  in  early  life.  During  early  life  mani- 
fold changes  take  place  continuously,  and  the  younger  the  individual 
the  more  rapid  are  these  changes.  Therefore  a  knowledge  of  the 
Uving  anatomy  of  each  period  of  growth  is  of  the  utmost  importance 
for  the  recognition  of  anomalies,  of  congenital  conditions,  and  of 
disease.  The  study  and  use  of  the  Roentgen  method  gives  us  a  large 
part  of  the  living  anatomy  and  pathology  of  either  an  early  or  late 
period  of  disease,  and  thus  enables  us  to  decide  upon  the  nature 
of  the  disease  long  before  the  findings  of  the  post-mortem  table 
can  be  utilized.  Even  anatomists  know  very  little  regarding  the 
changes  which  take  place  in  connection  with  the  appearance  and 
development  of  the  centres  of  ossification  at  different  ages,  yet 
without  this  knowledge  we  cannot  intelligently  treat  a  number  of 
diseases. 

During  the  development  of  the  bones  the  epiphyseal  line  illus- 
trates the  relationship  of  the  diaphysis  and  epiphysis  to  each  other 
and  to  their  surrounding  structures.  From  this  it  will  be  seen  that 
the  epiphyses  present  a  very  definite  anatomic  appearance  at  differ- 

2  17 


18  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

ent  periods.  This  not  only  occurs  in  the  epiphyses  of  a  special  joint, 
such  as  the  wrist,  but  in  the  epiphyses  of  the  different  joints  as 
compared  with  each  other.  Thus  the  long  bones  have  a  large 
epiphysis  at  each  end,  while  the  clavicle,  the  metatarsal  bones, 
and  the  phalanges  of  the  foot  and  hand  have  only  one.  It  is 
important  to  appreciate  that  the  various  epiphyses  gradually  appear 
and  grow  larger  and  larger  according  to  the  stage  of  development 
of  the  individual.  An  exact  knowledge  of  their  comparative  develop- 
ment is  therefore  of  great  use.  We  know  that  height  depends  upon 
the  development  of  the  epiphyses.  Suppose  we  are  examining  a 
child  twelve  years  old  who  has  the  height  of  a  child  of  six  years, 
and  we  wish  to  determine  what  the  chances  are  for  his  future  increase 
in  height;  that  is,  whether  he  will  eventually  be  a  dwarf.  On  exam- 
ining the  epiphyses,  if  we  find  that  they  correspond  to  the  normal 
ossification  of  a  child  of  twelve  years,  the  probability  is  that  the 
child  will  grow  very  little  more  in  height.  If,  on  the  contrary,  we 
find  that  the  degree  of  ossification  corresponds  to  the  normal  epiphy- 
seal development  of  six  years,  there  is  a  chance  that  the  growth  in 
height  may  begin  again.  It  is  manifest,  therefore,  that  unless  we 
have  this  exact  knowledge  of  the  changes  in  even  so  small  a  part 
of  the  entire  skeleton  as  the  epiphyses,  absolutely  normal  conditions 
may  be  mistaken  for  abnormal.  This  all  the  more  emphasizes  the 
importance  of  beginning  our  study  of  Roentgenology  by  acquiring  a 
thorough  knowledge  of  the  normal  living  anatomy  of  the  various 
stages  of  development. 

To  obtain  correct  data  of  these  normal  anatomic  conditions 
is  not  a  simple  question,  since  comparatively  little  aid  is  obtained 
from  the  many  anatomists  who  have  written  on  dead  anatomic  con- 
ditions. The  fact  is  that  the  knowledge  of  normal  living  anatomy  up 
to  the  present  time  has  mostly  depended  upon  what  has  been  derived 
from  dead  anatomy.     In  addition  to  this  the  anatomist  has  relied 


LIVING  NORMAL  ANATOMY.  19 

greatly  on  the  chronologic  age  of  the  individual  whose  dead  anatomy 
he  has  investigated,  and  has  stated  from  the  results  of  his  tabula- 
tions that  a  certain  development  takes  place  at  a  given  age.  We 
are  now  led  to  believe  that  this  chronologic  dead  anatomy  is  far 
from  correct,  and  that  it  does  not  approach  the  constant  standard 
which  we  need  in  making  an  exact  diagnosis  of  anatomic  conditions 
in  health  and  in  disease.  We  are  also  more  and  more  impressed, 
when  our  anatomic  studies  are  carried  out  on  the  living  subject  by 
means  of  the  Roentgen  method,  that  the  different  stages  of  develop- 
ment must  be  readjusted  and  made  to  correspond  to  some  other  con- 
dition more  constant  than  the  chronologic  one  of  age  in  months  and 
years.  By  taking  a  Roentgen  ray  of  a  large  number  of  apparently 
normal  children  in  different  stages  of  development,  it  has  been  shown 
that  chronologic  growth  is  far  from  exact  for  purposes  of  classifying 
children  for  school  and  athletics  in  comparison  with  the  anatomic 
changes  which  take  place  from  birth  to  pubescence.  Crampton's 
work  on  the  pubic  hair  in  the  latter  period  shows  that  there  is  a 
decided  variation  in  the  development  of  individuals  of  the  same  age. 
From  some  extensive  work  on  this  subject  in  which  I  have  been 
engaged  in  the  past  two  years,  I  have  come  to  the  conclusion  that 
when  we  wish  to  determine  the  normal  conditions  of  the  various 
stages  of  life,  some  standard  index,  such  as  the  changes  in  the  epiphy- 
ses, is  more  reliable  than  the  usually  accepted  standard  of  months 
and  years.  This  work  is  fully  described  in  Division  II.  I  have 
deduced  that,  given  an  individual  supposedly  normal  child,  the 
wrist  and  hand  are  the  most  practical  anatomic  parts  to  use  as  a 
general  standard  index  on  which  to  estabhsh  a  classification  based 
on  growth.  From  this  reasoning  I  have  concluded  that  if  this  hand 
and  wrist  standard  of  anatomic  age  proves  to  be  superior  in  exact- 
ness to  the  chronologic  age  usually  accepted,  it  will  be  of  the  greatest 
use  in  school  Ufe.    In  this  way  also  a  proper  adjustment  of  athletic 


20  THE  ROEXTGEN  RAY  IN  PEDIATRICS. 

contestants  can  be  made  by  grouping  the  corresponding  stages  of 
development  together  anatomically  rather  than  chronologically, 
thus  avoiding  overstrain  at  a  period  of  life  when  it  is  of  the  utmost 
importance  to  do  so.  As  much  more  work  will  be  needed  to  definitely 
determine  the  shorter  intervals  of  normal  li\dng  development,  I 
have  provisionally  grouped  a  number  of  chronologic  periods  together 
on  an  anatomic  basis.  The  average  periods  of  development  deter- 
mined in  the  past  by  chronologic  age,  weight,  or  height,  are  mani- 
festly fallacious.  We  must  make  many  observations  based  on  a 
new  system  deduced  from  anatomic  standards  before  healthy  chil- 
dren can  be  classified  according  to  what  they,  as  individuals,  need 
at  certain  periods  of  development  rather  than  because  they  are  of 
the  same  chronologic  age.  The  exact  meaning  of  this  is  that  a  group 
of  children  of  the  same  chronologic  age  in  months  and  years  may 
represent  perhaps  four  or  five  anatomic  ages. 

In  order  to  establish  certain  standards  by  which  we  can  pro- 
visionally determine  anatomic  age  in  early  life  I  have  studied  Roent- 
genographs of  healthy  children  representing  groups  of  chronologic 
age  corresponding  to  anatomic  conditions.  To  interpret  intelli- 
gently living  anatomic  conditions  as  shown  by  the  Roentgen  ray 
it  is  necessary  to  be  conversant  with  the  anatomic  conditions  which 
have  been  revealed  after  death.  The  most  important  of  these  con- 
ditions is  found  in  that  part  of  the  anatomy  of  the  bones  which  shows 
the  development  of  the  epiphyses  and  of  the  diaphyses.  Much  valu- 
able knowledge  can  be  acquired  also  from  a  careful  comparative 
study  of  the  organs  and  tissues,  which  is  of  great  use  in  the  differential 
diagnosis  of  various  diseases  by  the  ray.  It  is  certainly  very  impor- 
tant that  our  knowledge  of  the  centres  of  ossification  of  the  bones  at 
different  periods  of  their  development  should  be  perfected.  This 
can  be  accomplished  best  by  studying  the  living  normal  anatomy 
of  the  bones  by  means  of  the  Roentgen  ray  during  life.    In  the  series 


LIVING  NORMAL  ANATOMY.  21 

of  normal  anatomic  pictures  which  I  have  introduced  at  the  end  of 
this  division  it  should  be  noted  that  the  centres  of  ossification  are 
absent  at  first,  then  gradually  appear  as  small  plates,  and  finally 
assume  their  normal  size.  This  series  of  cases  starts  with  premature 
fife  and  is  carried  on  to  adolescence.  The  determination  of  abnormal 
conditions  of  the  lung  and  pleura,  the  degree  of  cardiac  enlargement, 
and  the  question  of  pericardial  effusion  in  the  less  obvious  cases 
must  also  often  rest  on  the  evidence  obtained  by  the  Roentgen  ray. 
This  grouping  by  anatomic  age  is  of  importance  surgically, 
because  the  surgeon  when  operating  on  an  individual  can  by  it 
often  learn  in  what  stage  of  development  is  the  especial  part  on 
which  he  is  operating.  It  is  also  of  importance  in  medical  cases  to 
take  into  consideration  the  relation  of  the  heart  to  the  lungs,  the 
relative  size  of  each,  and  the  different  degrees  of  the  cardiohepatic 
angle  in  its  various  stages  of  development.  The  practical  use  of 
the  pictures  of  these  groups  of  ages  in  surgery  and  in  medicine  is 
ob\'ious.  A  surgeon  is  about  to  operate  on  an  injury  to  a  joint,  or 
a  physician  wishes  to  determine  where  he  shall  operate  in  a 
pericardial  effusion.  Their  procedure  naturally  would  be  to  have 
a  Roentgenograph  taken  of  the  especial  case  before  them.  They 
will  then  turn  to  the  group  of  chronologic  age  or  rather  to  the  actual 
anatomic  division  of  age  which  corresponds  to  the  anatomic  age  of 
the  individual  whom  they  are  about  to  treat.  The  Roentgenograph 
corresponding  to  the  anatomic  age  of  the  especial  child  with  which 
they  are  dealing  will  then  show  them  whether  at  that  especial  period 
of  life  the  appearance  which  they  interpret  from  the  special  Roent- 
genograph of  their  patient  corresponds  to  the  general  Roentgeno- 
graph of  my  normal  anatomic  series.  If  it  does  correspond  they 
will  decide  that  the  picture  of  their  case  is  that  of  a  normal  condition, 
and  therefore  that  they  should  search  further  in  order  to  find  the 
real  diseased  condition.     If,  on  the  contrary,  the  picture  of  their 


22  THE  ROENTGEN  RAY  IX  PEDIATRICS. 

especial  case  does  not  correspond  to  such  normal  Roentgenograph, 
they  will  then  judge  that  they  are  dealing  either  with  a  pathologic 
process  or  with  an  anomaly  and  that  the  case  should  be  treated 
accordingly.  In  like  manner  in  looking  at  the  Roentgenograph 
which  represents  the  heart  it  will  be  seen  that  the  cardiohepatic 
angle  is  quite  distinct,  and  that  by  the  recognition  of  this  angle  on 
the  right  in  a  doubtful  case  of  suspected  pericardial  effusion,  the 
Roentgen  ray  would  aid  us  very  greatly  in  differentiating  a  normal 
or  an  enlarged  heart  from  an  effusion. 

Roentgenographs  of  the  living  normal  development  from  the 
seventh  to  the  ninth  month  of  intra-uterine  life  show  that  there  is 
comparatively  little  difference  between  these  ages,  with,  the  excep- 
tion that  the  upper  epiphysis  of  the  tibia  and  the  lower  epiphysis 
of  the  femur  appear  at  the  latter  date 

We  can  therefore  adopt  pro\'isionally  the  period  of  growth 
from  the  seventh  month  of  fetal  life  to  birth  as  a  group  of  anatomic 
growth,  and  call  it  Group  1  (Plate  2).  This  leads  us  to  observe 
how  long  these  early  anatomic  conditions  continue,  and  thus  for 
how  long  a  period  each  group  of  normal  anatomic  conditions  lasts. 

By  following  out  this  method  of  determination  we  can  represent 
roughly  different  groups  of  anatomic  age.  Thus  the  second  chrono- 
logic group  can  be  represented  by  a  period  of  life  lasting  from 
birth  to  the  time  when  the  first  bones  of  the  wrist  appear  in 
their  cartilaginous  surroundings.  In  Uke  manner  other  groups 
may  be  classified  until  the  whole  period  of  childhood  has  been 
gone  over  up  to  the  thirteenth  or  fourteenth  year.  There  is  much 
to  be  said  in  regard  to  these  intervening  periods  of  growth,  and 
much  practical  use  to  which  they  may  be  put.  I  have  thought, 
however,  that  it  would  be  best  first  to  show  a  number  of  illustra- 
tions of  the  child's  development  in  different  chronologic  periods, 
then,  in  a  division  of  the  book  b)-  itself  (Division  II) ,  to  show  to  what 


LIVING  NORMAL  ANATOMY.  23 

practical  use  this  anatomic  knowledge  can  be  put  in  the  every- 
day life  of  childhood.  I  have  represented,  therefore,  in  Division  I 
in  a  general  way  certain  periods  of  development  of  various  parts 
of  the  entire  bod}'.  I  have  begun  with  the  premature  infant  (Plate 
2),  and  ended  with  Plates  26  and  27,  which  include  about  the 
twelfth,  thirteenth,  and  fourteenth  years,  more  or  less. 

It  is  to  be  noticed  that  in  a  number  of  plates  which  represent 
other-nase  the  entire  skeleton  the  heads  do  not  appear.  The  reason 
for  this  is  that  it  is  extremely  difficult  to  obtain  a  good  Roentgeno- 
graph of  the  head  of  a  young  baby  unless  it  is  etherized.  Under 
normal  conditions  it  is  seldom  the  case  that  the  parents  will  allow 
the  infant  to  be  etherized  for  the  purpose  of  scientific  illustration. 
On  the  other  hand,  it  is  not  difficult  to  obtain  a  Roentgenograph 
of  the  premature  infant,  since  its  breathing  is  very  shallow  and  it 
often  does  not  move  its  head  for  many  minutes. 

The  acute  angle  made  by  the  right  side  of  the  heart  with  the 
upper  surface  of  the  liver  is  called  the  cardiohepatic  angle.  This  is 
well  shown  in  Plate  9.  It  is  of  great  importance  to  observe  this 
angle  carefully,  as  later  it  will  be  of  much  value  in  differentiating 
between  an  enlarged  heart  and  a  pericardial  effusion.  We  should 
also  note  the  areas  occupied  by  the  heart,  the  liver,  and  the  abdominal 
organs. 

After  this  preliminary  outline,  we  can  now  appreciate  why  we 
should  make  a  careful  study  of  li\ang  normal  anatomy  first,  and 
later  acquire  a  knowledge  of  living  abnormal  anatomy.  Ha\ang 
once  mastered  the  details  of  these  living  normal  conditions  through 
all  their  changes  of  development  from  the  very  beginning  of  life, 
the  diagnosis  of  disease  becomes  greatly  simplified. 

In  order  to  appreciate  why  the  various  parts  of  the  bone  differ 
in  their  radiabiiity  according  to  the  constituents  of  which  they  are 
composed,  I  shall  describe  briefly  the  structure  of  the  bones  and 
their  development. 


24  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

BONE 

Bone  is  the  hardest  structure  of  the  human  body,  but  also 
possesses  a  certain  degree  of  toughness  and  elasticity.  Its  color  in 
a  fresh  state  is  pinkish-white  externally  and  red  within.  On  exami- 
nation of  a  section  of  bone  we  find  two  kinds  of  tissue,  one  of  which 
forms  the  dense  hard  external  covering  and  is  called  the  cortex; 
the  other,  which  forms  the  interior  of  the  bone  and  consists  of  fibres 
and  of  lamelUe  which  join  and  form  a  reticular  structure,  is  called 
the  cancellous.  It  is  to  the  variations  in  the  relative  quantities  of 
these  tissues  that  the  difference  in  weight  and  size  of  the  different 
bones,  and  also  of  the  different  parts  of  the  same  bone,  is  due. 
The  bones  are  permeated  by  blood-vessels  and  are  surrounded  by  a 
fibrous  membrane  called  the  periosteum,  by  which  the  blood  supply 
is  carried  to  the  cortex.  The  long  bones  have  a  cavity  filled  with 
marrow,  and  are  lined  with  a  vascular  structure  called  the  medullary 
membrane. 

Periosteum. — The  periosteum  normally  adheres  to  the  bone 
in  nearly  all  parts,  excepting  its  extremities,  which  in  early  life  are 
cartilaginous.  It  is  thick  and  vascular,  and  is  incorporated  at  either 
end  of  the  bone  with  the  epiphyseal  cartilage. 

The  constituents  of  bone,  according  to  Gray,  are  as  follows: 


Organic  matter Gelatin  and  blood-vessels 33.30 

'  Phosphate  of  lime 51.04 

Carbonate  of  lime 11.30 

Fluoride  of  calcium 2.00 

Phosphate  of  magnesia 1.16 

Soda  and  chloride  of  sodium 1.20 


Inorganic  and  earthy  matter < 


It  is  by  the  predominance  of  the  inorganic  constituents  of  the 
bone  with  their  varying  atomic  weights  that  we  are  able  by  means 
of  the  Roentgen  method  to  differentiate  the  various  parts  of  the 
bone  clearly. 

As  it  is  easier  and  more  practical  to  study  a  Roentgenograph 


LIVING  NORMAL  ANATOMY  25 

as  a  whole,  and  in  order  to  appreciate  all  the  advantages  of  this 
method,  we  should  learn  to  look  at  the  living  anatomy  of  either 
head,  thorax,  abdomen,  or  limbs  as  a  whole,  and  thus  determine  the 
dependence  of  one  part  on  the  other  as  representing  the  interdepend- 
ence of  all  the  abnormal  conditions  present.  Having  once  mastered 
the  picture  in  broad  perspective,  the  especial  disease  for  which  we 
are  looking  can  in  this  way  be  better  differentiated  and  intelligently 
studied.  When  we  have  done  this  it  is  evident  that,  in  such  abnormal 
conditions  as  can  be  portrayed  by  the  Roentgen  ray,  the  Roent- 
gen method  is  complete,  rational,  and  satisfactory,  and  is  therefore 
verj^  important  for  the  purpose  of  differential  diagnosis. 

Diaphyses  and  Epiphyses. — The  long  bones  have  an  epiphy- 
sis at  each  end,  with  the  exception  of  the  clavicle,  metatarsal  and 
metacarpal  bones,  and  the  phalanges  of  the  hand  and  foot,  which 
have  only  one.  In  a  premature  infant  of  seven  months  the  long 
bones  have  no  ossific  centres  representing  the  epiphyses  (see  Plate 
2).  The  epiphyses  are  the  most  important  centres  of  the  skeleton, 
for  on  them  depends  its  future  development,  especially  in  infancy 
and  childhood,  and  when  these  centres  are  impaired  there  result 
far-reaching  influences  in  later  life.  A  thorough  knowledge  of  the 
different  changes  which  take  place  in  even  these  small  areas  is  very 
important,  for  these  centres  are  where  disease  may  begin,  from 
which  disease  may  disseminate,  and  where  it  may  lead  to  disastrous 
consequences  b)^  leaving  its  permanent  marks. 

The  following  table  gives  the  time  of  the  appearance  of  the 
ossific  centres  of  the  epiphyses,  and  represents  the  results  of  our 
study  at  the  Children's  Hospital  of  a  large  number  of  children. 

It  must,  however,  be  remembered  that  most  of  these  estimated 
figures  depend  upon  dissections  and  in  some  cases  are  erroneous. 
Many  of  them  have,  however,  been  verified  or  corrected  by  our 
observations  on  living  subjects. 


26  THE  ROENTGEN  RAY  IX  PEDIATRICS. 

Table  1. — Time  of  the  Appearance  of  the  Epiphyses. 
Claxicle 18  years. 

ITPER   extremity. 

-.  f  upper  epiphysis  (head) 6  to  8  months. 

■  I  tuberosities 3d  year.     (2d  to  3d  year.) 

'  capitellum 1st  year.     (2d  to  3d  year.) 

trochlea 10th  year. 

external  epicondyle 12th  to  13th  year. 

[  internal  epicondyle .^th  year. 

Radius,  lower  epiphysis 2d  to  4th  year. 

Radius,  upper  epiphysis 5th  year. 

-,.  f  lower  epiphysis  5th  to  7th  year. 

I  styloid  process 4th  year. 

Ulna,  upper  epiphysis 10th  year. 

Carpus birth  to  15th  year.' 

Metacarpus about  third  year. 

Phalanges  (1st,  2d, and  3d  rows  successively) 3d  to  4th  year. 


Humerus,  lower  epiphysis  . 


Femur 


LOWER   EXTREMITY. 

'lower  epiphysis 4  to  6  weeks  before  birth. 

upper  epiphysis within  6  months. 

trochanter  major 5th  year. 

trochanter  minor 12th  to  14th  year. 

Pat«lla  2d  to  3d  year. 

„.,  .  I  upper  epiphysis 8th  to  9th  month  of  fetal  life. 

I  lower  epiphysis 6  or  12  months  to  2  years. 

Fibula         I  "^^''  ^P'I*y^'^ ^^'^  y®*""- 

'  ■ '  ■  \  lower  epiphysis 2d  to  3d  year. 

Tarsus  6th  month  of  fetal  life  to  4th  year.' 

Metatarsus 3d  to  8th  year. 

Phalanges 4th  to  7th  year  (page  31). 

Os  innominatum 8th  to  19th  week  of  fetal  life  (page  32). 

» For  development  of  individual  bones  .see  pages  27-32. 

Development  of  Bone. — In  the  fetus  up  to  about  the  fourth 
month  the  osseous  system  represented  by  the  long  bones  is  more  or 
less  cartilaginous,  while  that  part  which  is  represented  by  the  cranial 
bones  is  intramembranous.  At  the  third  or  fourth  month  of  fetal 
life  the  shafts  of  the  bones  show  a  cortex  and  a  medullary  cavity, 
but  at  birth  no  epiphyses  excepting  those  above  mentioned,  such 
as  of  the  femur  and  of  the  tibia,  are  present. 

There  is  also  a  third  kind  of  ossification  which  is  called  sub- 
periosteal. 


LIVING  NORMAL  ANATOMY.  27 

As  the  long  bones  are  the  most  important  in  the  osseous  system 
and  are  better  understood  than  the  others,  I  shall  mention  in  brief 
the  changes  which  they  undergo  in  their  development.  During  the 
first  three  months  of  intra-uterine  Ufe  (this  varjang  in  the  indi\adual 
fetus)  the  osseous  system  is  practically  cartilaginous.  Soon  after 
this  a  process  begins  in  the  centre  and  extends  towards  the 
extremities.  Subsequently  a  process  begins  here  and  there  in  the 
end  of  the  bone  and  gradually  extends.  The  epiphyses,  however, 
do  not  join  the  shaft  until  growth  has  ceased,  and  they  remain 
separated  by  a  layer  of  cartilaginous  tissue  called  the  epiphyseal 
cartilage  or  zone  of  proliferation.  Early  in  the  process  of  ossification 
the  cartilage  cells  of  the  centres  of  ossification  enlarge  and  arrange 
themselves  in  rows,  which  gradually  are  separated  by  an  increase 
in  the  matrix  in  which  they  are  imbedded.  A  calcareous  deposit 
now  takes  place  in  the  matrix  between  the  cells,  which  become 
further  separated  by  columns  of  longitudinal  calcified  matrix,  which 
gives  a  granular  opaque  appearance.  Some  of  the  matrix  becomes 
calcified  into  transverse  columns  extending  from  one  longitudinal 
column  to  another.  In  this  way  cartilaginous  cells  are  enclosed  in 
cavities  of  an  oblong  shape  Tvuth  walls  of  calcified  matrix.  These 
cavities  are  called  primary  areolae. 

Humerus. — The  humerus  usually  develops  by  seven  centres, 
but  sometimes  by  eight: 

One  for  the  shaft.  One  for  the  capitellum. 

One  for  the  head.  One  for  the  trochlea. 

One  for  the  tuberosities.  One  for  each  condyle. 

At  the  eighth  week  in  fetal  life  the  nucleus  of  the  shaft  appears, 
and  at  birth  the  whole  shaft  is  practically  ossified.  The  extremities, 
however,  remain  cartilaginous.  The  ossific  centre  first  to  appear 
after  birth  (normal)  is  the  capitellum  at  about  the  first  year.  At 
the  sixth  month  an  ossific  centre  of  the  upper  epiphysis  of  the  hu- 


28  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

merus  appears  at  about  the  same  time  as  the  head  of  the  femur. 
At  the  beginning  of  the  third  year  a  centre  for  the  tuberosities  appears. 
This  ossification  is  sometimes,  but  rarely,  by  two  centres.  During 
the  middle  of  the  fifth  year  or  later  the  centres  for  the  head  and 
tuberosity  have  united  to  form  a  single  large  epiphysis.  The  carti- 
lage, however,  may  persist  and  on  examination  with  the  Roentgen 
ray  be  confused  with  a  fracture.  The  lower  end  of  the  humerus 
beside  the  capitellum  has  the  ossific  centre  for  the  internal  condyle 
at  the  fifth  year.  The  external  condyle  appears  about  the  twelfth 
to  the  thirteenth  year. 

Radius. — The  radius  develops  by  three  centres: 

One  for  the  shaft  (eighth  to  ninth  week  of  fetal  life). 

One  for  each  extremity. 
At  birth  the  bone  is  well  ossified,  but  at  the  beginning  of  the 
third  year  the  ossific  centre  for  the  lower  epiphysis  may  appear, 
and  between  the  fifth  and   sixth  year   the  ossific   centres  for  the 
upper  epiphysis  appear. 

Ulna. — The  ulna  develops  by  three  centres: 

One  for  the  shaft  (eighth  week  of  fetal  life). 

One  for  the  lower  epiphysis. 

One  for  the  olecranon. 
At  birth  both  extremities  are  cartilaginous.  The  lower  epiphysis 
appears  at  about  the  fifth  to  the  seventh  year.  Sometimes  this 
epiphysis  appears  as  two  centres,  later  uniting  to  form  one.  At  the 
tenth  year,  sometimes  a  little  later,  the  epiphysis  of  the  olecranon 
process  (upper  epiphysis  of  ulna)  appears. 

Carpus. — The  carpal  bones  develop  commonly  from  a  single 
centre,  and  are  all  cartilaginous  at  birth.  The  ossific  centres  under 
normal  conditions  usually  appear  in  the  followdng  order : 

The  OS  magnum  and  the  unciform  appear  verj'  soon  after 
birth,  the  os  magnum  usually  appearing  first. 


LIVING  NORMAL  ANATOMY.  29 

The  cuneiform,  about  the  second  or  third  year. 
The  semilunar,  about  the  fourth  or  fifth  year. 
The  trapezium,  about  the  fifth  year. 
The  scaphoid,  about  the  fifth  to  sixth  year. 
The  trapezoid,  about  the  sixth  to  eighth  year. 
The  pisiform,  about  the  twelfth  j^ear. 
According  to  Pryor  the  appearance  of  the  trapezium,  scaphoid, 
and  trapezoid  varies,  and  in  his  cases  the  trapezoid  precedes  the 
trapezium,  but  the  scaphoid  precedes  the  trapezoid. 

He  has  also  found  that  at  the  same  chronologic  age  the  carpal 
bones  of  girls  are  in  advance  of  those  of  boys,  especially  during 
the  stage  of  pubescence. 

These  observations  of  Pryor,  however,  do  not  invahdate  the 
deductions  on  which  my  principle  of  developmental  strength  is 
based;  for,  as  I  look  at  the  question,  it  is  the  number  of  carpal 
bones,  rather  than  the  order  in  which  they  come,  which  makes 
this  strength. 

Metacarpus. — The  metacarpal  bones  are  developed  from  two 
centres : 

One  for  the  shaft  (sixth  week  of  fetal  life) . 
One  for  the  epiphyses. 
The  ossific  centre  of  the  epiphyses  for  the  metacarpal  bones 
appears  about  the  third  year,  usually  a  Uttle  earUer. 
Phalanges. — The  phalanges  develop  by  two  centres: 
One  for  the  shaft  (sixth  week  of  fetal  life) . 
One  for  the  proximal  ends. 
The  ossific  centres  of  the  proximal  ends  appear  at  about  the 
third  year. 

Femur. — The  femur  is  developed  by  five  centres: 
One  for  the  shaft. 
One  for  each  extremity. 
One  for  the  trochanters  (greater  and  lesser). 


30  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

The  ossific  centre  of  the  lower  end  of  the  shaft  may  appear 
about  the  end  of  the  eighth  month  of  fetal  life,  but  usually  in  the 
early  part  of  the  ninth  month.  An  infant  at  full  term  shows  a  well 
developed  lower  epiphysis.  The  lower  epiphysis  appears  at  about 
the  ninth  month  of  fetal  life.  The  ossific  centre  for  the  head  of  the 
femur  (upper  epiphysis)  appears  usually  within  the  first  six  months. 
The  great  trochanter  is  not  seen  definitely  until  the  fifth  year  and 
joins  the  shaft  at  about  the  eighteenth  year.  The  lesser  trochanter 
appears  from  the  twelfth  to  the  fourteenth  year  and  joins  the  shaft 
at  the  eighteenth  year.  It  is  to  be  noticed  that  the  shaft  and 
the  diaphyses  are  rounded  and  smooth  (Plate  18)  presenting  no 
sharp  or  ragged  edges.  This  is  an  important  point,  as  an  early 
infection  or  a  nutritional  disturbance  is  first  manifested  by  a  ragged 
and  irregular  diaphysis. 

Patella. — The  patella  develops  by  a  single  centre.  It  has  a 
density  more  definite  than  cartilage  as  a  rule,  but  not  so  definite 
as  bone.  The  tendon  of  the  quadriceps  extensor  passing  over  the 
patella  is  continuous  below  with  the  fibres  of  the  ligamentum  patellae. 
The  centre  of  ossification  of  the  patella  appears  between  the  second 
and  third  year.  The  development  of  the  patella  is  completed  at 
about  the  thirteenth  or  fourteenth  year.  The  bone  sometimes, 
though  rarely,  develops  from  two  centres  placed  side  by  side.  It 
sometimes  remains  cartilaginous  as  late  as  the  sixth  year. 

Tibia. — The  tibia  develops  by  three  centres,  one  for  the  shaft 
and  one  for  each  extremity.  The  ossific  centre  for  the  upper  epiphy- 
sis of  the  tibia  appears  before  birth,  at  the  same  relative  time  as  the 
lower  extremity  of  the  femur,  that  is,  at  about  the  last  of  the  eighth 
month  or  the  first  of  the  ninth  month.  The  lower  epiphysis  appears 
soon  after  birth,  usually  about  the  middle  to  the  last  of  the  first 
year. 

Fibula. — The  fibula  is  developed  by  three  centres,  one  for  the 
shaft  (eighth  week  of  fetal  life?),  and  one  for  each  extremity.    The 


LIVING  NORMAL  ANATOMY.  31 

lower  epiphysis  appears  first  between  the  second  and  third  year, 
and  the  upper  epiphysis  appears  about  the  fourth  year. 

Tarsus. — The  tarsal  bones  develop  by  a  single  centre;  they 
appear  approximately  as  follows: 

Os  calcis  (sixth  month  of  fetal  life).    This  bone  shows  an 
irregular  development  from  sometimes  two  or  three 
centres  of  ossification.     This  normal  condition   must 
be   carefully   considered   when    some   abnormality   is 
being  differentiated  from  a  fracture. 
Astragalus  (seventh  month  of  fetal  life). 
Cuboid  (ninth  month  of  fetal  life). 
External  cuneiform  (first  year). 
Internal  cuneiform  (third  year). 
Middle  cuneiform  (fourth  year). 
Scaphoid  (fourth  year). 
The  ossific  centre  for  the  epiphysis  of  the  os  calcis  appears  at 
the  ninth  year,  and  sometimes  unites  before  puberty,  but  usually 
soon  after.    It  at  times  develops  from  two  centres. 

Metatarsus. — The   metatarsal   bones   are   developed  from   two 
centres : 

One  for  the  shaft  (ninth  week  of  fetal  life). 

One  for  the  distal  extremities  of  the  four  outer  metatarsal 

bones. 
One  for  the  proximal  end  of  the  metatarsal  bone  of  the 
great  toe. 
The  ossific  centre  of  the  proximal  end  of  the  epiphysis  of  the 
first  metatarsal  bone  appears  about  the  third  year,  while  the  centres 
of  the  distal  epiphyses  of  the  others  appear  about  the  fifth  to  eighth 
year. 

Phalanges. — The  phalanges  develop  by  two  centres; 
One  for  the  shaft  (eighth  week  of  fetal  life). 
One  for  the  proximal  extremity. 


32 


THE  ROENTGEN  RAY  IN  PEDIATRICS. 


The  ossific  centre  of  the  first  row  of  phalanges  appears  at  the 
fourth  year,  of  the  second  row  from  the  sixth  to  the  seventh  year, 
and  of  the  third  row  in  the  ninth  j^ear. 

Os  Innominatum . — The  os  innominatum  develops  by  eight 
centres,  three  primary  and  five  secondary : 

Crest  of  ilium. 


Primary 


Ilium. 
Ischium. 
Os  pubis. 


Secondary  (each 
with  one  centre) 


Anterior  inferior  spinous  pro- 
cess (more  common  in 
the  male). 

Tuberosity  of  the  ischium. 

Symphysis  pubis  (more  com- 
mon in  the  female). 

Acetabulum. 


These  ossific  centres  appear  in  the  following  order: 

The  ilium  above  the  sciatic  notch  (eighth  week  of  fetal  life) . 
The  body  of  the  ischium  (twelfth  week  of  fetal  life) . 
The  body  of  the  os  pubis  (sixteenth  to  nineteenth  week  of 
fetal  life). 
At  birth  the  ilium,  ischium,  and  os  pubis  are  separated,  the 
crests  and  the  bottom  of  the  acetabulum  being  cartilaginous.     At 
the  fourth  year  the  rami  of  the  ischium  and  pubis  begin  to  grow 
toward  each  other,  thus  completing  the  obturator  foramen.    This 
occurs  between  the  sixth,  seventh,  and  eighth  years.    The  cartilage 
of  the  acetabulum  becomes  ossified  by  the  thirteenth  year.     The 
ischium  and  ilium  unite  at  the  age  of  puberty. 

TEETH 

The  role  which  at  the  present  time  the  teeth  of  children  play 
in  practical  medicine  is  so  great  that  a  description  of  the  normal 
teeth  as  preparator}^  to  the  study  of  abnormal  conditions  is  quite 
necessary. 


LIVING  NORMAL  ANATOMY.  33 

Since  the  use  of  the  Roentgen  ray  in  dentistry  has  been  estab- 
lished this  role  has  become  more  and  more  extensive  and  important. 
No  dental  surgeon  or  odontologist  is  fully  equipped  unless  he  avails 
himself  of  the  valuable  addition  to  the  instruments  for  diagnostic 
precision  which  we  possess  in  this  wonderfully  accurate  discovery 
of  modern  science. 

It  is  not  my  intention  to  go  deeply  into  the  subject  of  the 
teeth,  or  of  the  anomalies  found  in  and  about  the  jaws.  I  shall 
simply  show  that  many  conditions  that  heretofore  have  been  seen 
only  in  the  beautifully  prepared  specimens  of  the  museums  can  now 
by  means  of  the  Roentgen  method  be  studied  during  Ufe. 

Enamel  is  formed  from  the  epiblastic  layer.  In  the  same  manner 
are  formed  the  skin,  the  epithelium  of  the  mouth, — except  the  tongue 
and  the  back  part  of  the  floor  of  the  mouth, — and  the  appendages 
of  the  skin,  such  as  the  hair,  nails,  epithelium,  glands,  and  nervous 
system.  Dentine  and  cementum  are  formed  from  the  mesoblastic 
layer.  In  this  way  also  are  formed  the  skeleton,  muscular  tissue, 
and  connective  tissue.  Enamel  is  a  substance  composed  of  hme 
salts  deposited  by  organic  tissues  which  disappear  during  its  forma- 
tion. The  entire  surface  of  the  enamel  is  finely  striated,  the  striae 
being  transverse  to  the  long  axis  of  the  crown.  In  addition  to  this 
fine  striation  there  may  be  a  few  deeper  and  more  pronounced  grooves 
or  pits  which  are  pathologic  and  are  marks  of  a  check  in  develop- 
ment more  or  less  complete.  Two  views  have  been  held  as  to  the 
formation  of  enamel.  One  is  that  it  is  formed  by  the  actual  conver- 
sion of  the  cells  of  the  enamel  organ  into  enamel.  The  other  is  that 
it  is  in  some  sense  secreted  or  shed  by  these  cells.  In  support  of  this 
latter  theory  there  is  the  authority  of  well-known  investigators,  but 
some  of  the  grounds  on  which  their  decisions  are  based  are  appear- 
ances which  are  open  to  a  different  interpretation. 

The  deformities  in  the  human  teeth  are  found  in  the  enamel 

3 


34  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

and  are  due  to  checks  in  the  development  of  or  destruction  of  the 
ameloblasts.  It  becomes  of  great  importance,  therefore,  that 
the  causes  of  this  check  or  destruction  be  anticipated  as  much 
as  possible. 

Disturbances  in  the  tissues  formed  from  the  epiblastic  layer  of 
cells  in  the  embr\-o  will  in  the  new-born  and  up  to  the  third  or  fourth 
year  be  likely  to  show  their  effects  in  the  formation  of  the  enamel 
of  the  permanent  teeth.  Such  diseases  as  sj^jhilis,  tuberculosis, 
rhachitis,  measles,  and  scarlet  fever  have  long  been  considered  as 
causes  of  these  deformities,  although  it  has  been  impossible  in  many 
cases  where  deformities  exist  to  find  any  history  of  these  diseases. 

The  diseases  of  nutrition,  while  they  may  not  cause  deformities 
in  the  enamel,  can  so  weaken  the  structure  of  the  entire  tooth  that 
it  may  be  impossible  to  preserve  it.  For  this  reason  it  should  be 
understood  how  important  it  is  to  protect  young  children  during 
the  period  of  the  first  dentition  from  these  infectious  diseases  and 
from  the  so-called  diseases  of  nutrition. 

While  we  recognize  the  serious  results  which  arise  from  disturb- 
ances of  nutrition,  those  which  arise  from  infectious  diseases  are 
not  so  commonly  understood  and  accepted. 

For  various  reasons  the  laity  are  apt  to  say  and  to  believe  that 
it  is  well  to  allow  the  other  children  in  a  family  where  one  child  is 
infected,  to  be  exposed  to  the  disease.  It  is  the  duty  of  the  physician 
under  these  circumstances  to  impress  upon  the  parents  that  such 
grave  secondary  conditions  as  have  just  been  described  should  be 
avoided.  This  is,  of  course,  only  one  of  the  reasons  for  protesting 
against  allowing  a  young  child  to  be  exposed  unnecessarily  to 
an  infectious  disease. 

In  Table  2  and  Table  3  I  have  indicated  in  a  general  way  when 
the  different  groups  of  temporary  and  permanent  teeth  respectively 
are  to  be  expected  to  erupt. 


LIVING  NORMAL  ANATOMY.  35 

There  may  be  a  variation  of  a  number  of  weeks  in  the  eruption 
of  the  various  groups  given  in  Table  2. 

Table  2.— Temporary  Teeth,  First  Dentition,  20  in  Ntjmber. 
Dental  Periods.  Eruption  of  Groups  of  Teeth.  Beginning  of  Calcification. 

I.  6  to  8  months 2  middle  lower  incisors. 


I.  b  to  8  months 2  middle  lower  incisors 1  .„,.  ,     ,,»,,., 

,T    o*    in         .1                   A             ■     ■  }•  20th  week  of  fetal  life. 

II.  8  to  10  months 4  upper  incisors J 

'  24th  week  of  fetal  life. 


III.  12  to  14  months 2  lateral  lower  mcisors 

and  4  first  molars. 

IV.  18  to  20  months 4  cuspids 

V.  24  to  30  months 4  second  molars 


There  may  be  a  variation  of  a  number  of  years  in  the  eruption 
of  the  various  groups  given  in  Table  3. 

Table  3. — Peb-manent  Teeth,  Second  Dentition,  32  in  Number. 

YeaiE.  Groups.  Beginning  of  Calcification. 

6 4  first  molars 9th  month  of  fetal  life. 

7 4  middle  incisors 1^^     ,^  xt       t 

.                                            ,  1  4      1  •     •  >  8  to  12  months  of  age. 

8 4  lateral  incisors J 

9 4  first  bicuspids 3  years. 

10 4  second  bicuspids 4  years. 

11 4  cuspids 20th  to  24th  month. 

12 4  second  molars 5  years. 

17 4  third  molars 9  to  14  years. 

At  the  time  of  birth  calcification  of  the  entire  crowns  of  the 
temporary  central  incisors  and  lateral  incisors,  and  of  about  one- 
third  of  the  cuspid  teeth,  usually  takes  place.  About  one-half  of 
the  first  temporary  molars,  a  little  less  than  one-half  of  the  second 
temporary  molars,  and  the  tips  of  the  cusps  of  the  first  permanent 
molars  also  appear  at  this  time  (see  Plate  3  and  Plate  5).  The 
calcification  of  the  roots  progresses  until  at  about  the  eighteenth 
month  when  the  apices  of  the  temporary  superior  central  incisors 
should  be  completely  calcified.  At  the  sixteenth  month  the  apices 
of  the  temporary  lateral  incisors  become  calcified,  and  at  about 
the  twentieth  month  those  of  the  first  temporary  molars.  At  the 
thirtieth  month  the  apices  of  the  temporary  cuspids  and  those 
of  the  second  temporary  molars  become  calcified.     These  teeth 


36  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

begin  to  erupt  when  about  one-half  of  the  root  has  become  calcified. 
Tomes  gives  as  stages  of  calcification  at  birth:  "A  full  half  of  the 
length  of  the  crown  of  the  central  incisor,  about  half  that  of  the 
laterals,  and  the  tip  only  of  the  cuspids.  At  birth  the  first  temporary' 
molars  are  complete  as  to  their  masticating  surfaces.  The  second 
temporary'  molars  have  their  cusps  more  or  less  irregularly  united, 
in  many  cases  the  four  cusps  being  united  into  a  ring  of  dentine, 
the  dentine  in  the  central  depression  of  the  crown  not  being  yet 
formed." 

Cases  of  deformity  of  the  jaws  or  threatened  deformity  should 
be  placed  under  treatment  at  an  early  age,  in  most  instances  before 
the  temporary  teeth  have  given  place  to  the  permanent  ones.  Room 
can  thus  be  made  for  the  misplaced  or  unerupted  tooth  to  come  into 
position  where  it  will  stay  without  long  retention.  If  the  Roentgen 
examination  is  resorted  to  at  an  early  period  much  trouble  will  be 
saved  for  the  child  as  well  as  for  the  orthodontist. 

(Plate  91,  Division  V,  shows  the  normal  temporarj-  teeth  in  a 
child  three  years  old.) 

During  the  period  between  the  fourth  and  sixth  years  separation 
takes  place  between  the  temporary  teeth  anterior  to  the  first  tem- 
porary molar.  This  is  due  to  the  increased  outward  and  forward 
development  of  the  jaws,  and  also  to  the  advancing  permanent 
teeth  which  lie  in  the  lingual  aspect  of  the  temporary  cuspids  and 
incisors.  The  bicuspids,  which  take  the  place  of  the  temporary 
molars,  lie  directly  above  and  below  the  latter,  their  crowns  when 
in  normal  position  being  surrounded  by  the  temporary'  molar  roots. 
In  many  cases  the  second  temporary  molar  is  retained  for  quite  a 
period  of  time,  occupying  more  space  than  will  be  needed  for  the 
second  bicuspid.  Under  certain  conditions  it  may  be  necessar}-^  to 
extract,  although  the  temporary  molars  are  firm.  Owing  to  the 
relation  of  the  crowns  of  the  bicuspids  to  the  temporary  molar  roots, 


LIVING  NORMAL  ANATOMY.  37 

these  parti}'  developed  permanent  teeth  may  be  sacrificed  by  the 
extraction  of  the  temporar}-  molars.  This  depends,  however,  upon 
whether  the  roots  of  the  latter  have  reached  a  stage  in  absorption 
which  will  render  them  powerless  to  disturb  the  position  of  the  under- 
lying teeth.  The  Roentgen  examination  is  invaluable  in  these  cases, 
for  the  unnecessary  loss  of  one  or  more  bicuspids  may  cause  serious 
deformities.  The  calcification  of  the  first  permanent  molar  starts  at 
the  ninth  month  of  fetal  fife  (see  Plate  3) . 

On  an  average  it  is  found  that  at  the  first  year  after  birth  the 
calcification  of  the  tips  of  the  central  and  lateral  permanent  incisors 
has  taken  place.  In  the  second  year  one-sixth  of  the  crowns  of 
these  teeth  has  been  completed,  and  the  tip  of  the  cuspids.  At 
the  third  year  the  tip  of  the  first  bicuspid  has  begun  to  calcify.  At 
the  fourth  year  about  one-half  of  the  central  and  lateral  crowns, 
one-third  of  the  cuspid  crowns,  and  the  tips  of  the  second  bicuspids 
have  become  calcified.  Between  the  seventh  and  eighth  year  calcifi- 
cation has  taken  place  in  about  one-half  of  the  root  of  the  central 
and  lateral  incisors,  has  just  begun  in  the  cuspid  roots,  and  has  just 
finished  in  the  crowns  of  the  bicuspids.  The  first  permanent  molar 
has  kept  just  a  Uttle  ahead  of  the  central  incisors  in  calcification, 
and  at  about  the  fourth  year,  when  one-half  of  the  central  crown 
has  become  calcified,  two-thirds  of  the  crown  of  the  first  molar  has 
been  completed.  In  the  fifth  year  we  find  the  crown  of  the  first 
molar  fully  calcified,  the  central  incisors  almost  so,  and  the  tips  of 
the  cusps  of  the  second  molar  just  beginning.  Plate  91  shows  the 
stage  of  development  of  the  first  permanent  molar  in  a  child  three 
years  old.  The  average  time  for  the  development  of  this  tooth  is 
during  the  fifth  year. 

At  a  given  stage  in  the  development  of  a  tooth  it  is  due  to  erupt, 
and  if  the  question  arises  regarding  its  eruption,  the  Roentgen 
examination  will  determine  whether  from  its  development  it  is  due 


38  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

or  overdue.  If  the  picture  indicates  an  abnormality,  steps  should 
be  taken  to  correct  it.  If  we  are  expecting  a  tooth  to  erupt,  say  the 
cuspid,  any  time  between  the  ninth  and  fourteenth  year,  there  are 
five  intervening  years  in  which  serious  trouble  may  occur.  For 
instance,  the  tooth  was  due  to  erupt  at  nine  years.  From  uncer- 
tainty the  case  might  be  allowed  to  progress  with  the  result  that 
through  further  development  of  the  root  and  lack  of  space,  it  might 
be  deflected  from  its  course  and  later  would  have  to  be  forced  into 
its  place.  It  is  possible,  also,  that  one  or  both  lateral  incisors  may 
be  missing.  If  these  teeth  do  not  erupt  at  the  proper  time  it  is  wise 
to  resort  to  the  Roentgen  examination  in  order  to  determine  their 
position  or  absence. 

Plate  27  shows  the  normal  development  of  the  permanent 
teeth  and  the  Roentgen  method  of  determining  whether  a  doubtful 
tooth  belongs  to  the  temporary  or  permanent  groups.  This  plate 
shows  very  plainly  all  of  the  permanent  teeth  that  should  have 
erupted  at  this  age  in  the  upper  jaw  posterior  to  the  cuspids. 

CHRONOLOGIC  EXAMPLES  OF  NORMAL  LIVING  ANATOMY 

After  these  preliminary  remarks  on  anatomic  development,  it 
will  be  useful  to  look  at  a  number  of  plates  of  normal  living  anatomy 
in  early  life  which  I  have  arranged  chronologically.  The  degrees 
of  development  shown,  however,  do  not  necessarily  correspond  in 
sequence  to  the  chronologic  ages.  A  careful  inspection  of  these 
plates  will  demonstrate  to  the  student  the  significance  of  the  distinc- 
tion between  chronologic  age  and  anatomic  growth  which  I  shall 
fully  explain  in  Division  II,  and  the  results  of  which  seem  to  show 
that  the  child's  well-being,  in  determining  rules  for  its  life,  is  best 
protected  by  relying  on  anatomic  rather  than  on  chronologic  age. 

When  the  details  of  these  normal  li\dng  conditions  through  all 
their  stages  of  development  from  the  very  beginning  of  life  are 


LIVIXG  NORMAL  AXATOMY.  39 

mastered,  the  diagnosis  of  disease  will  be  greatly  simplified.  We 
shall  then  be  able  to  recognize  in  our  search  for  a  diseased  condi- 
tion whether  it  is  a  stage  of  normal  rather  than  abnormal  develop- 
ment in  the  special  individual  whom  we  have  before  us. 

In  the  third  month  of  intra-uterine  life  the  skeleton  of  the 
fetus  is  practically  completed. 

Plate  2  is  that  of  a  premature  infant  seven  months  old. 
The  head  of  this  infant,  which  was  under  my  care  at  the  Chil- 
dren's Hospital,  shows  quite  a  broad  zone  of  increased  radia- 
bility  in  both  the  frontal  and  upper  parietal  regions  and  in  the 
occipital  and  postparietal,  where  there  is  an  almost  purely  carti- 
laginous condition.  The  cranial  bones  at  this  stage  of  development 
show  the  condition  of  intramembranous  ossification.  All  the  sinuses 
are  absent  except  the  orbit,  which  is  quite  distinct,  as  is  also 
the  nasal  cavity.  Both  the  upper  and  lower  jaws  show  indistinct 
pictures  of  the  teeth  in  their  cartilaginous  surroundings,  but  the 
density  is  not  sufficient  to  differentiate  them.  At  the  base  of 
the  skull  is  to  be  noticed  the  rudimentary'  atlas  and  axis  and 
then  the  vertebral  column  through  its  whole  length.  Especially 
marked  is  the  extreme  radiabiUty  of  the  intravertebral  disks  in 
comparison  with  the  lessened  radiabiUty  of  the  bodies  of  the 
vertebrae,  which,  however,  also  show  a  cartilaginous  condition  of 
the  transverse  processes  throughout  the  whole  length  of  the  spine. 
Starting  from  above  it  should  be  noted  in  comparison  with  the 
radiabiUty  in  the  cervical  region  the  decreased  radiabiUty  in  the 
cardiac  region,  where  the  density  of  the  heart  is  added  to 
that  of  the  spine.  Between  the  ribs  is  seen  the  great  radiabiUty 
of  the  lung.  The  greater  density  of  the  liver  is  seen  just  below 
the  lung,  and  below  this  again  round  light  areas  representing  parts 
of  the  intestine.  The  pelvis  is  in  a  semi-cartilaginous  condition. 
To  be  noted  is  the  entire  absence  of  bonv  structure  in  the  front  of 


40  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

the  pelvis,  where  the  ihum,  ischium,  and  os  pubis  are  widely  sepa- 
rated. All  the  long  bones  are  developed,  but  no  epiphyses  are 
present  in  any  of  the  joints.  The  clavicles  are  ossified.  The  humerus, 
the  radius,  the  ulna,  the  femur,  the  tibia,  and  the  fibula  are  repre- 
sented entirely  by  their  diaphyses,  which,  however,  are  somewhat 
cartilaginous  towards  the  ends  at  this  age.  No  carpal  bones  are 
present  at  this  stage  of  development,  and  no  tarsal  bones  except  the 
OS  calcis  and  the  astragalus.  To  be  noted  also  is  the  greater  radia- 
bility  of  the  central  part  of  the  tibia  which  shows  the  marrow  light 
in  comparison  with  the  dark  edges  representing  the  cortex.  The 
small  size  of  the  entire  skeleton  will  be  appreciated  if  we  observe 
that  the  trunk  in  comparison  with  a  moderate-sized  safety-pin  is 
only  four  times  the  length  of  the  pin. 

Plate  3  represents  the  normal  head  of  an  infant  aged  ten 
days.  The  proportion  of  the  face  to  the  head  at  this  age  is  very 
small.  (For  a  further  description  of  the  face  and  cranium  see 
"Pediatrics,"  fifth  edition,  page  26.)  The  antrum  shows  no  signs 
of  development  and  does  not  appear  until  the  eighth  or  the  tenth 
month,  except  that  it  has  gradually  become  a  marked  depression  in 
the  wall  of  the  nasal  cavity  just  at  the  time  of  the  eruption  of  the 
first  temporary  teeth.  The  first  temporary  teeth  are  seen  in  their 
crypts  partly  calcified. 

In  the  upper  jaw  the  incisors  are  indistinctly  seen. 

The  cusps  of  the  temporary  molars  show  the  calcification  which 
corresponds  to  a  development  of  ten  days. 

Plate  4  represents  the  thorax  and  upper  legs  of  an  infant  ten 
days  old.  There  is  nothing  especially  noticeable  about  the  thorax 
and  abdomen  to  distinguish  it  from  that  of  the  fetus  of  nine  months. 

The  ilium,  ischium,  and  os  pubis  are  still  ununited,  and  their 
cartilaginous  separation  still  covers  quite  a  broad  area. 

While  in  the  premature  infant  the  lower  epiphysis  of  the  femur 


LIVING  NORMAL  ANATOMY.  41 

as  seen  in  Plate  2  has  not  appeared,  it  has  become  quite  distinct 
in  this  infant  of  ten  days. 

Also  to  be  noted  in  this  infant,  which  is  the  same  subject  whose 
head  has  just  been  described,  is  the  great  radiability  at  the  head  of 
the  femur,  and  that  the  cardiohepatic  angle  is  clearly  defined. 

To  be  noted  in  connection  with  these  earlier  stages  of  develop- 
ment is  the  picture  of  a  normal  stomach  artificially  dilated  in  an 
infant  five  weeks  old  (Division  VII,  Plate  140). 

Plate  5  shows  the  head  of  an  infant  ten  weeks  old.  The 
first  and  second  temporary  molars  show  the  degree  of  calcification 
which  has  taken  place  in  their  crowns.  Anterior  to  the  first  tem- 
porary molar  the  teeth  are  indistinct  and  the  picture  is  confused. 

Plate  6  shows  a  lower  extremity  of  the  same  infant  ten 
weeks  old.  To  be  especially  noticed  is  the  still  undeveloped  condi- 
tion of  the  bones  of  the  pelvis.  The  lower  epiphysis  of  the  femur 
has  become  quite  prominent,  and  this  is  also  the  case  with  the  upper 
epiphysis  of  the  tibia.  The  other  epiphyses  are  not  yet  seen.  The 
bones  of  the  foot  have  increased  in  size  and  lessened  in  radiability 
in  comparison  with  the  same  bones  shown  in  Plate  2.  They  are 
the  OS  calcis,  the  astragalus,  and  lower  down  the  cuboid. 

Plate  7  shows  the  hand  of  an  infant  three  months  old.  No 
epiphyses  are  present,  and  the  only  carpal  bones  that  have  appeared 
are  the  os  magnum  and  the  unciform. 

Plate  8  shows  the  normal  thorax,  humeri,  and  elbows  of  an 
infant  from  two  to  three  months  old.  The  only  epiphysis  present 
is  the  upper  epiphysis  of  the  humerus. 

Plate  9  shows  the  entire  skeleton,  excepting  the  head,  of  a 
girl  six  months  old.  To  be  especially  noted  are  the  cardiohepatic 
angle  on  the  infant's  right,  the  clearly  defined  outline  of  the  stomach, 
and  the  presence  of  the  lower  epiphysis  of  the  femur  and  the  upper 
epiphysis  of  the  tibia.     There  is  no  especial  change  in  the  spinal 


42  THE  ROENTGEN  RAY  IX  PEDIATRICS. 

column,  except  that  the  radiability  in  comparison  with  that  in  the 
plate  of  the  earlier  age  just  shown  has  gradually  decreased.  The  out- 
line of  the  stomach  is  very  clear  at  both  the  cardiac  and  pyloric 
extremities.  The  front  of  the  pelvis  is  still  in  a  cartilaginous  condi- 
tion and  is  widely  open.  The  shafts  of  the  long  bones  are  clearly 
marked.  The  cortex  of  the  femur  shows  its  lessened  radiability  in 
comparison  with  the  radiability  of  the  marrow.  It  is  possible  that  the 
area  marked  B  in  the  cardiac  end  of  the  stomach  may  represent  the 
left  kidney.  The  upper  epiphysis  of  the  humerus  has  appeared.  No 
epiphysis  has  yet  appeared  at  the  lower  end  of  the  humerus.  There 
are  no  epiphyses  seen  at  the  upper  or  at  the  lower  ends  of  the  radius 
and  ulna.  The  bones  of  the  carpus  are  very  indistinct  if  seen  at  all, 
the  OS  magnum  and  cuneiform  bones  possibly  being  shown  in  the 
midst  of  the  irregular  area  to  the  left  of  the  left  wrist.  Neither  the 
upper  nor  the  lower  epiphysis  of  the  fibula  has  yet  appeared.  The 
upper  epiphysis  of  the  tibia  is  present.  On  examining  the  tarsal 
bones  it  will  be  seen  that  not  only  the  os  calcis  and  the  astragalus 
are  present,  but  that  the  cuboid  also  seems  to  be  present,  while  in 
the  picture  of  the  premature  infant  (Plate  2)  the  cuboid  has  not 
yet  appeared. 

Plate  10  shows  the  normal  trunk  of  a  girl  twelve  months  old. 
The  different  organs  as  described  in  the  legend  belonging  to  this 
plate  are  seen  plainly. 

Plate  1 1  shows  the  skeleton  of  a  girl  about  twenty-four  months 
old.  In  this  plate  the  transverse  processes  of  the  cervical  vertebrae 
show  a  decreased  radiability  and  are  more  ossified.  The  ribs  show  a 
greater  density,  and  the  stomach  is  not  so  clearly  defined  as  in  Plate 
9.  The  front  of  the  pelvis  is  not  so  widely  apart,  ossification 
having  apparently  taken  place  in  the  ischium  and  ilium.  The 
sacrum  has  become  still  less  cartilaginous  as  shown  by  its  lessened 
radiability.    The  shafts  of  the  bones  still  show  great  radiability  at 


LIVING  NORMAL  ANATOMY.  43 

their  distal  ends,  but  their  cortex  is  distinct.  The  epiphysis  of  the 
upper  end  of  the  humerus  has  increased  in  size  and  shows  lessened 
radiability  as  compared  with  the  infant  of  six  months.  There  is  no 
epiphysis  at  the  lower  part  of  the  humerus.  A  small  epiphysis  of 
considerable  radiability  is  seen  at  the  lower  end  of  the  radius.  No 
epiphysis  is  seen  at  the  lower  end  of  the  ulna.  The  carpal  bones 
have  now  become  much  more  distinct.  The  os  magnum  and  the 
unciform  are  plainly  in  sight  with  their  rapidly  increasing  density. 
Just  behind  the  unciform  bone  is  seen  a  minute  highly  radiable 
carpal  bone,  probably  the  cuneiform,  although  this  bone  is  usually 
not  supposed  to  appear  until  the  third  year.  The  metacarpal  bones 
show  the  epiphyses.  The  epiphyses  of  the  phalanges  of  the  fingers 
are  present.  The  epiphysis  of  the  upper  end  of  the  femur  has  become 
much  larger  than  seen  in  Plate  9  and  shows  decreased  radiability. 
The  epiphysis  of  the  lower  end  of  the  femur  has  increased  much  in 
size,  and  the  epiphyseal  line  is  much  decreased,  its  boundaries  being 
smooth  and  regular.  It  is  to  be  noticed  that  the  trochanter  major 
and  trochanter  minor  have  not  yet  appeared.  The  epiphysis  of  the 
upper  end  of  the  tibia  has  come  plainly  into  ■view.  The  epiphysis 
of  the  upper  end  of  the  fibula  is  not  yet  seen,  but  is  present  at  the 
lower  end.  The  tarsal  bones  have  much  increased  in  size  and  show 
decreased  radiability,  the  cuboid  and  external  cuneiform  apparently 
being  absent.  The  metatarsal  bones  and  the  phalanges  of  the  foot 
are  too  much  massed  to  be  differentiated. 

Plate  12  shows  the  skeleton  of  an  infant  about  three  and 
a  half  years  old.  In  this  plate  there  is  no  especial  change  in  the 
density  of  the  cervical  vertebrae.  The  lumbar  vertebrae  are,  however, 
unusually  distinct  and  show  decidedly  lessened  radiability  in  their 
bodies.  There  is  somewhat  greater  radiability  than  is  seen  in  the 
younger  subjects  already  described.  There  is  still  no  epiphysis  at  the 
upper  end  of  the  ulna  or  of  the  radius,  but  the  epiphysis  at  the  lower 


44  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

end  of  the  radius  has  increased  in  size.  There  is  no  epiphysis  seen 
at  the  lower  end  of  the  ulna.  The  carpal  bones  have  become  more 
distinct  and  increased  in  size,  being  represented  bj'  the  os  mag- 
num, the  unciform  and  the  cuneiform  bones.  The  epiphysis  of 
the  upper  end  of  the  humerus  has  increased  in  size.  The  capitellum 
is  shown  at  the  lower  end  of  the  humerus.  The  heads  of  the  met- 
acarpal bones,  the  epiphysis  of  the  metacarpal  bone  of  the  thumb, 
and  the  epiphyses  of  the  proximal  ends  of  the  first  phalanges  are 
coming  into  view.  The  epiphysis  of  the  upper  end  of  the  femur 
has  become  larger  and  the  epiphyseal  line  narrower.  The  epiphyses 
of  the  lower  end  of  the  femur  and  of  the  upper  end  of  the  tibia 
have  increased  in  size.  The  epiphysis  of  the  lower  end  of  the  tibia 
shows  increase  in  size  and  the  epiphyseal  line  is  narrower.  The 
epiphysis  of  the  lower  end  of  the  fibula  is  seen  just  behind  the 
astragalus.  The  cuboid,  external  cuneiform,  and  internal  cuneiform 
bones  have  become  more  prominent.  No  especial  change  is  noticed 
in  the  metatarsal  bones  nor  in  the  phalanges. 

Plate  13  shows  the  knees  and  lower  limbs  of  a  child  three 
years  old. 

Plate  14  shows  the  normal  foot  of  a  child  five  years  old,  which 
should  be  compared  with  the  abnormal  foot  of  a  child  three  years 
old  in  Division  III,  Plate  56. 

Plate  15  shows  the  skeleton  of  a  child  about  six  years  old. 
There  is  no  especial  change  to  be  noted  in  the  thorax  of  this  child. 
The  bodies  of  the  transverse  processes  have  become  much  more 
ossified  and  show  greater  density  and  lessened  radiability.  The 
iUum  and  ischium  are  closely  approaching  each  other  and  are  grad- 
ually completing  the  acetabulum.  The  processes  of  the  ischium  and 
of  the  OS  pubis  have  almost  closed  in  so  as  to  form  the  obturator 
foramen.  The  front  of  the  pelvis  is  closing.  The  lower  epiphysis 
of  the  ulna  has  begun  to  appear  and  is  represented  by  two  fine  points. 


LIVING  NORMAL  ANATOMY.  45 

The  lower  epiphysis  of  the  radius  is  gradually  approaching  its  lower 
diaphysis.  Starting  with  the  os  magnum,  we  see  to  the  right  the 
unciform  and  next  to  this  the  cuneiform,  then  the  semilunar  in  the 
centre  and  just  below  the  epiphysis  of  the  radius,  then  the  scaphoid, 
the  trapezoid,  and  the  trapezium.  The  four  metacarpal  bones  show 
their  epiphyses  plainly.  The  first  metacarpal  bone  (thumb)  shows 
its  epiphysis.  The  phalanges  show  their  epiphyses  plainly.  The 
upper  epiphysis  of  the  femur  is  increasing  in  size.  The  greater  tro- 
chanter appears  verj^  plainly  and  also  the  lesser  trochanter.  The 
lower  epiphysis  of  the  femur  has  become  much  more  developed. 
The  tarsal  and  metatarsal  bones  have  become  larger,  but  excepting 
the  OS  calcis  and  the  astragalus  they  are  not  clearly  dififerentiated 
in  the  plate  on  account  of  a  side  \'iew  ha\'ing  been  taken. 

Plate  16  shows  the  shoulder  of  a  child  six  years  old. 

Plate  17  shows  the  elbow  of  a  child  six  years  old.  This  is  the 
same  subject  as  Plate  16  and  Plate  18. 

Plate  18  represents  the  knee  of  a  child  six  years  old,  and  is 
the  same  subject  as  Plate  16  and  Plate  17. 

Plate  19  shows  the  normal  thorax  of  a  child  six  years  old. 

Plate  20  shows  the  normal  hands  of  a  boy  nine  years  old. 

Plate  21  shows  the  normal  thorax,  arm  and  hand,  pehns, 
and  upper  legs  of  a  child  ten  years  old.  In  this  case  the  ray  has 
been  especially  directed  on  the  pelvis  and  hips,  there  being  nothing 
special  to  be  noted  in  the  picture  of  the  thorax.  The  sacrum  is  seen 
very  plainly  in  the  brim  of  the  peh-is.  The  epiphysis  of  the  upper 
end  of  the  humerus  is  definitely  developed,  as  are  the  external  and 
internal  condyles  of  the  humerus,  the  epiphysis  of  the  scapula,  and 
the  glenoid  cavaty.  The  upper  epiphyses  of  the  radius  and  of  the 
ulna  show  plainly.  The  rami  of  the  ischium  and  the  os  pubis  have 
joined  so  as  to  form  the  obturator  foramen.  The  ilium  and  the 
ischium  have  not  yet  joined.      The  epiphyseal   line  of  the  upper 


46  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

epiphysis  of  the  femur  has  become  quite  narrow  and  is  smooth 
and  even.  Especially  to  be  noted  is  the  epiphysis  of  the  greater 
trochanter.  The  epiphyseal  line  of  the  lower  end  of  the  radius  is 
quite  narrow,  and  the  epiphysis  of  the  lower  end  of  the  ulna  is 
distinct. 

Plate  22  shows  the  knees,  lower  legs,  and  foot  of  the  same 
subject.  Especially  to  be  noted  are  the  well-developed  epiphyses 
of  the  lower  end  of  the  femur  and  the  upper  end  of  the  tibia  with 
their  narrow,  clearly  defined  epiphyseal  lines.  The  lower  epiphysis 
of  the  tibia  is  present,  and  the  upper  and  lower  epiphj'ses  of  the 
fibula  also  are  present.  All  the  bones  of  the  tarsus  appear  in  this 
picture.  Especially  to  be  noted  is  the  small  pin-head  development 
of  the  middle  cuneiform  and  of  the  scaphoid:  the  latter  is  seen  to 
have  two  centres  of  ossification. 

Plate  23  shows  the  normal  spine  of  a  child  ten  years  old. 

Plate  24  shows  the  skeleton  of  a  child  twelve  years  old.  All 
the  epiphyses  are  well  developed,  and  all  the  bones  of  the  wrist 
are  present.  Note  especially  the  pisiform  bone  overlying  the 
unciform  bone.  The  ihum  and  ischium  have  practically  joined, 
forming  the  acetabulum.  The  os  pubis  is  still  open.  The  epiphyseal 
line  of  the  greater  trochanter  has  almost  disappeared.  The  epiphysis 
of  the  OS  calcis  with  its  narrow  epiphyseal  Une  is  evident.  All  the 
carpal  and  tarsal  bones  are  present. 

Plate  25  shows  the  normal  elbow  of  a  child  of  twelve  3^ears. 
The  details  of  this  plate  are  described  in  the  legend. 

Plate  26  shows  the  normal  thorax  of  a  boy  twelve  years  old. 
Especially  to  be  noted  is  the  epiphysis  of  the  humerus,  which  is 
clearly  defined  and  shows  its  union  with  the  diaphysis  well  advanced. 
(The  complete  union  occurs  from  the  eighteenth  to  the  twentieth 
year.)  Note  the  decidedly  lessened  radiability  of  the  heart  and  the 
sharply  defined  cardiohepatic  angle. 


LIVING  NORMAL  ANATOMY.  47 

Plate  27  shows  the  head  of  a  boy  thirteen  years  old  with  a 
normal  permanent  set  of  teeth.  This  plate  shows  very  plainly  all 
of  the  permanent  teeth  that  should  have  erupted  at  this  age.  In 
the  upper  jaw  posterior  to  the  cuspid  the  bicuspids  are  seen.  The 
root  of  the  second  bicuspid  and  a  small  cavity  can  be  seen  in  the 
floor  of  the  antrum  immediately  above  it.  The  first  molar  is 
in  similar  relation  to  the  antrum,  and  small  cavities  can  be  seen 
in  its  floor  over  the  anterior  and  posterior  buccal  roots.  The 
second  molar  roots  do  not  show  so  clearly.  The  third  molar,  only 
partly  formed,  can  be  plainly  seen  in  its  crypt.  In  the  lower  jaw 
the  third  molar  can  be  seen  with  the  distinct  outline  of  its  crypt 
and  some  calcification  of  its  crown.  The  roots  of  the  second  molar 
are  not  yet  formed.  The  crown  of  the  first  molar  has  been  exten- 
sively filled,  which  accounts  for  the  change  in  the  density.  The  roots 
appear  normal.  The  anterior  root  is  not  clearly  shown,  nor  are  the 
roots  of  the  teeth  anterior  to  the  first  molar,  on  account  of  the 
interposition  of  the  teeth  on  the  opposite  side  of  the  jaw.  The  object 
of  this  illustrative  examination  was  to  determine  the  nature  of  a 
tooth  in  the  position  of  the  first  bicuspid.  Here  it  is  seen  that  the 
crown  is  much  deformed,  due  to  caries,  in  this  case  making  it  impos- 
sible to  determine  whether  it  was  the  first  bicuspid  or  the  first  tem- 
porary molar,  other  indications  pointing  to  the  latter.  The  plate 
has  not  given  us  any  assistance  on  this  point,  however,  for  a  tooth 
extensively  reconstructed  on  the  other  side  of  the  jaw  lies  in  the 
same  field,  destroying  all  faint  outlines  by  its  greater  density. 

The  doubtful  tooth  in  question  was  again  Roentgenographed 
by  using  a  film  inside  the  mouth,  and  the  result  is  shown  in  the  pic- 
ture at  the  bottom  of  the  plate,  so  that  it  could  be  determined  that 
it  was  the  first  bicuspid  instead  of  a  temporary  molar.  If  it  had 
been  the  first  inferior  temporary  molar,  it  would  have  had  four 
roots  and  would  have  shown  two  in  the  picture.  The  second  root 
shown  in  the  picture,  however,  declares  the  tooth's  identity. 


PLATE  2. 
PREMATURE  INFANT. 

7  months.     (Reduced  58%.) 

A.  Frontal  and  upper  parietal  region. 

B.  Occipital  and  postparietal  region. 

C.  Orbit. 

D.  Axis. 

X.  Nasal  cavity. 

E.  Shows  an  anterior  view  of  the  third  intervertebral  cartilage. 

F.  The  arrow  points  toward  the  sixth  vertebra. 

G.  Heart. 
H.  Lung. 

/.  Coils  of  intestine. 

J.  Cardiac  end  of  stomach. 

K.  Liver. 

L.  Ramus  of  os  pubis. 

M.  Clavicles. 

N.  Shaft  of  humerus. 

0.  Shaft  of  radius. 

P.  Shaft  of  ulna. 

Q.  Shaft  of  femur. 

R.  Shaft  of  tibia. 

S.  Shaft  of  fibula. 

T.  Os  calcis. 

U.  Astragalus. 

y.  Phalanges  of  hand. 


Plate  2 


I'l.ATE  3. 

Ago  10  days.    (Reduced  30%.) 

A.  Area  of  incroasod  density  in  occipital  bone. 

B.  Anterior  fontancllc. 

C.  Line  of  parietal  and  fiontal  sutures. 
T).  Posterior  fontancllc. 

E,  F.  Denser  and  liglilcr  areas  in  occipital  bone  represent  the 
tables. 
G.  Beginnins^  dcvelopnicnt  of  the  frontal  sinus. 
H.  Orbit. 

/.  Superior  maxilla. 
J.  Ethmoidal  cells. 

K.  Calcified  cusps  of  first  and  second  tcmporai-\-  molars. 
L.  Crypt  of  first  lower  permanent  molar. 


PliATE  3 


PLATE  4. 
TRUNK  AXD  LEGS. 

Age  10  clays.     (Heiluced  46%.) 

,4 .   Lower  epiphysis  of  femur,  at  birth. 


Plate  4 


« 


-n  ' 


PLATE  5. 

Ace  10  weeks.     (Reduced  215%.) 

A.  Anterior  fontancllo. 

B.  Upper  lateral  incisor  and  temporary  cuspid. 

C.  Upi)er  first  temporary  molar. 

D.  Crvjjt  of  upper  left  first  permanent  molar. 

E.  Crypt  of  lower  left  first  permanent  molar. 


PliATE  5 


PLATE  6. 
PELVIS— LEG— FOOT. 

AKe  10  weeks.    (Life  size.) 

NoniKil  development. 


Plate  6 


/ 


PLATE  7. 
NORMAL  HAXD 

Age  3  months.     (Life  size.) 

Tlu>  OH  nia.EnuiH  and  luicifonn  bonos  havo  appear(><I,  hut  no 
other  bonert  of  the  hand   and   wrist  an;  prcaent. 


Platk  7 


PLATE  8. 
NORMAL  THORAX,  SHOULDERS,  AND  ELBOWS. 

Age  3  m.iinliH.     (UeduceJ  25%.) 


Plate  8 


PL  ATI',  II. 

NORMAL  LXLAXT. 

Age  I)  moutlis.    (Reduced  05%.) 

A.  ('anriolu'])atic  anj^le. 

B.  Stomach. 

C.  Large  iiik'sliiR-  (ascendini;  c-ohmj. 

D.  Cortex  of  femur. 

E.  Medulla  of  femur. 

F.  Epiphy.^^is  of  humeru.-^. 

G.  Clavicle. 
H.  Carpus. 

I.  Upper  epiphysis  of  feuuir. 

J.  Lower  epiphysis  of  femur. 

K.  l'pi)er  epiphysis  of  til:>ia. 

L.  Tarsus. 

(By  mistake  in  joininji  the  two  sections  of  the  Koentgeno- 
graph  they  liave  not  overlapped  sufficiently,  which  gives  the 
infant  sc!ven  lumbar  vertebrx'  instead  of  five.) 


Pl,ate  9 


PLATE  10. 
XORMAL  THORAX. 

Age  12  month,*.     (Rpduceil  24%.) 

.-1.  Large  intestine,  descending. 

B.  Large  intestine,  ascending. 

C.  Liver. 

D.  Lungs. 

E.  Heart  and  spine. 

F.  Cardiac  end  of  stomach. 
G'.  Pyloric  end  of  stomach. 


Plate  10 


PLATE   11. 

Age  2  year-.     (Reduced  705%  ) 

.4.  Uppor  opiphysis  of  humrni.^. 

B.  CapitcUutu. 

C.  Lower  epiphysis  of  radius. 

D.  Cuneiform. 

h'.   Epiphysis  of  head  of  femur. 
F.  Epiphyse.s  of  tibia  and  fihuhi. 

The  lower  epiphysis  of  tlic  femur  and  the  up])er  epiphysis 
of  the  tibia  are  also  shown. 


PliATE  11 


# 


I  t 


PLAT1-;   IJ. 

Age  3  years. 

■4.  Ilium. 

B.  I.schium. 

C.  Os  pubis. 

D.  Obturator  foiumcn. 

E.  CapitcUum. 

F.  Lower  epiphysis  of  fibula. 

G.  Uncertain — possibly  the  tra])eziuiii,  perhaps  the  scaphoic 
H.  Upper  epiphysis  of  humerus. 


Pl.ATK  12 


/" 


/ 


mv 

'in 


\ 


•  I 


f9 


^J^^ 


%^ 


PLATI".   13. 

NORMAL  KXEKS.  LOWER  LEGS.  AXD  ANKLES. 

ISoy,  .3  years  of  age.     (Retlueed  2SJ%.) 

.1.  Lowei'  (liaphvsis  of  tViniir. 

B.  Lower  epiphysLs  of  femur. 

C.  Upper  epiphysis  of  tibia. 

D.  Foramen  of  nutrient  artery  of  til)ia. 

E.  Cortex  of  tibia. 

F.  Lower  epiphysi.s  of  tibia. 

G.  Lower  epiphysis  of  fibula. 


Platk  13 


PLATE  11. 
NORMAL  I'OOT. 

Cliild,  aKc  5  yt'ar.-t      (Life  size.) 

The  structure  of  the  bones  is  normal. 

The  epiphyses  of  the  tibia  and  fibula  arc  present. 

The  large  tarsal  bones  arc  not  yet  massed. 

The  epiphysis  of  the  os  calcis  has  not  yet  appeared. 

The  cuboid  corresponds  to  that  of  the  normal  at  the  fifth 
year.  Tlie  group  represented  liy  the  cuneiform  bones  is  iKir- 
mally  developed,  and  the  siii:dl  scaphoid  is  seen  just  ahii\-c  this 
group  and  above  llic  cid)oid. 

The  metatarsal  and  phalangeal  bones  are  too  much  massed 
to  be  differentiated. 


Plate  14 


PLATE   l.j. 

Age  U  years.    (Reduce<l  03%.) 

A.  Obturator  foramen. 

B.  Lower  epiphj-sis  of  ulna. 

C.  O;^  magnum. 

D.  Cuneiform. 

E.  Trapezoid. 

F.  Region  of  greater  trochanter. 
a.  Region  of  lesser  trochanter. 

Z.   Epiphvjiis  of  fibula,  partly  beneath  astragalus 

1.  Astragalus. 

2.  Os  calcis. 


Plate  15 


jK 


X 


PLATE  16. 

NORMAL  SHOULDER. 

Age  6  year**.    (Reduced  lli%.)    (Same  subject  as  Plates  17  and  18.) 

Especially  to  bo  noted  Is  the  fusion  of  the  greater  tuberonity 
with  the  head  of  the  humeru.s. 


PXATE  16 


I'LATK   17. 
NORMAL  ELBOW. 

Age  G  years.     (Life  size.)     (Same  subject  as  Plates  10  and  18.) 

A.  Shows  the  capitelluni  of  the  humerus. 


Plate  17 


PLATE  18. 
NORMAL  KNEE. 

Age  G  years.     (Life  size.)     (Same  subject  as  Plates  in  and  17.) 

A.  Points  to  upper  epiphysis  of  the  fibuhi. 


PI.ATE  18 


PT.AT]':   19. 
NORMAL  THORAX. 

Age  0  years.     (Reduced  45%.) 


Plate  19 


I'LATE  20. 
NORMAL  HANDS. 

Boy  9  year-s  old. 


PIM.TE  20 


I 

I 


PLATE  21. 
NORMAL  CHILD. 

Af;e  10  years.     (Ueiluceti  about  66%  )     (Same  subject  a.s  Plate  22.) 

A .  Closed  rami  of  pubos  and  ischium. 
II    I'ljpor  epiphysi<:  of  femur. 
C.   (ircater  trochunter. 


PT.ATK   21 


PLATE  22. 

NORMAL  KXEES,  LOWER  LEGS,  AXD  FOOT. 
Age  10  years.    (Reduccfi  ahoiit  .5G%.)      (Same  subject  as  Plate  21.) 

7).  T"|)])('i'  (']/iphysis  of  fibula. 

/:.  Two  centres  of  o.ssification  of  scaphoid. 


Plate  23 


D- 


D 


)  , 


PLATE  23. 

NORMAL  SPINE. 

Age  10  years.    (Reduced  33 J%.) 

Note  the  clearly  defined  details  of  the  vertebrse. 


Plate  23 


PLATE  24. 

Ape  12  years 

A.  Pisiform  bone. 

Xotc  fiiiily  defined  epiphysis  of  external  condyle. 


Plate  24 


PLATE  25. 

NORMAL  ELBOW. 

Affc  12  years.    (Reduced  24%  ) 

A.  CapitfUum. 

B.  Internal  condyle. 

C.  Epiphysis  of  upper  end  of  ulna. — olecranon  process. 

D.  Upper  epiphysis  of  radiud. 


Plate  25 


PLATE  26. 
NORMAL  THORAX. 

Boy  12  years.     (Reduced  oO%.) 

Arms  raised  above  head. 
.4 .  Upper  epiphysis  of  humerus. 
B.   Canliohepatic  angle. 


Pr.ATK  20 


PLAT]':  27. 

RKillT  811)1-:  OK  HEAD. 

Boy  13  years  old.    (Life  size. 

.1.  I''i'(iiit;il  sinus. 

B.  Orbit. 

C.  Sphenoidiil  sinus. 

D.  Second  upper  hicusijiil. 

E.  Antrum. 

F.  First  upper  molar. 

G.  Third  upper  molar. 
H.  Third  lower  molar. 

/.   First  lower  bicuspid. 
/".   First  lower  bicuspid  takt'U  witli  fihn. 


PI.ATK  27 


Division  II 

ILLUSTRATIVE  U5E  OF  LIVING  NORMAL  ANATOMY 

The  consideration  of  chronologic  and  anatomic  age  in  early 
life  has  become  very  important,  since  the  work  of  various  investiga- 
tors, especially  of  Crampton,  has  shown  the  great  discrepancy  which 
exists  between  them.  '  This  discrepancy  is  not  merely  of  scientific 
interest;  on  the  contrary,  it  opens  up  a  vast  field  for  the  study  of 
the  management  of  child  life  and  for  the  change  from  existing  customs 
in  connection  with  it. 

Up  to  the  present  time  the  age  of  an  individual  has  been  com- 
puted by  years,  and  this  rule  will  probably  always  hold  good  from 
a  legal  point  of  view  in  all  civilized  communities.  The  question 
whether  chronologic  age  is  a  wise  division  during  the  formative 
period  of  early  life  when  brought  to  bear  on  our  school  systems, 
whether  in  classifying  and  grading  children  as  to  their  studies,  or 
pitting  them  against  each  other  in  athletic  sports,  becomes  a  very 
serious  one.  Again,  when  the  important  question  of  child-labor  ig 
brought  before  us  and  we  have  to  determine  at  what  age  a  child 
should  be  allowed  to  work,  we  can  at  once  see  that  a  chronologic 
division  for  this  purpose  is  not  only  insufficient  but  clearly  perni- 
cious. It  behooves  us  then  to  look  at  the  question  of  age  in  early 
life:  (1)  from  a  chronologic  point  of  view, — manifestly  legal, — (2)  as 
regards  athletics, — manifestly  anatomic, — (3)  educational,  as  regards 
school  grades, — manifestly  a  combination  of  chronologic,  physiologic, 
and  anatomic  conditions. 

1.  Legal  chronologic  age  does  not  enter  into  this  discussion. 

2.  Anatomic  age  should  first  be  carefully  studied  before  school 
and  child-labor  can  be  dealt  with  intelhgently.  From  a  medical 
point  of  view  the  physiologic  and  anatomic  conditions  can  for  the 

4  49 


50  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

present  be  considered  as  one,  since  at  this  point  of  the  discussion  we 
can  consider  the  normal  physiologic  development  of  the  various 
functions  to  correspond  to  and  keep  pace  with  the  normal  anatomic 
development.  I  wish  it  to  be  understood,  however,  that  this  supposi- 
tion is  merely  preliminary  to  some  work  which  I  expect  to  carry  out 
later  on  this  very  subject,  namely,  whether  it  is  true  that  deductions 
made  from  a  physiologic  standpoint  can  be  properly  used  when 
compared  with  anatomic  conditions.  This  will  be  a  much  more 
difficult  investigation  and  probably  will  merely  show  that  there 
is  such  correspondence  between  the  physiology  and  the  anatomy 
of  human  beings.  This,  however,  should  by  no  means  be  taken  for 
granted  and  is  still  sub  judice.  The  great  importance  of  an  exact 
knowledge  of  the  anatomic  development  as  expressed  by  the  bones 
and  joints  to  avoid  overstrain  at  a  time  of  Ufe  when  this  avoidance 
is  of  prime  necessity  should  be  impressed  forcibly  upon  the  pubUc 
in  general.  This  knowledge  should  be  acquired  especially  by  those 
who  have  charge  of  the  athletic  grading  of  boys  and  girls,  whether 
in  football  or  basketball  or  general  gymnastics.  Having  determined 
what  the  anatomic  growth  is  at  different  stages  of  development 
during  the  growing  period,  we  can  then  apply  this  knowledge  to  the 
broad  question  of  education  and  of  child-labor.  The  problem  at 
once  presents  itself  as  to  the  best  method  for  determining  the  nor- 
mal anatomic  development  from  birth  to  perhaps  fourteen  years,  and 
how  to  express  it  in  as  small  intervening  periods  as  is  possible  and 
practical.  This  anatomic  knowledge,  however,  should  represent 
the  different  stages  of  living  anatomy  rather  than  depend  on  the 
results  obtained  from  studying  dead  anatomic  conditions.  As  our 
knowledge  advances  the  anatomic  intervals  will  become  shorter 
and  shorter.  There  is  no  doubt  that  from  a  somewhat  extended 
study  of  the  subject  which  I  have  made  during  the  last  two  years 
a  much  closer  and  more  reUable  estimation  of  age  from  an  anatomic 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  51 

point  of  view  can  be  made  than  could  possibly  be  acquired  from  a 
chronologic.  My  belief  is  that  in  the  future  we  shall  determine  age, 
whether  for  gymnastics,  athletic  sports,  kindergarten,  school,  or 
child-labor,  by  means  of  anatomic  conditions  rather  than  by  chrono- 
logic periods.  It  has  been  shown  by  a  number  of  writers  that  growth 
is  influenced  by  race  and  heredity  and  by  social  and  hygienic  condi- 
tions. Thus,  for  example,  the  Scandinavians,  Scotch,  and  light- 
haired  Germans  are  tall,  while  the  Italians  and  French  are  short. 
The  offspring  of  a  mixed  anatomic  parentage  is  more  Uke  the  large 
parent.  The  upper  middle  social  stratum  is  most  favorable  for 
large  growth,  as  is  the  upper  middle  hygienic  stratum.  It  is  known 
that  at  the  period  of  pubescence  the  girl  increases  in  growth  more 
rapidly  than  does  the  boy,  and  that  at  or  about  the  period  of  puberty 
the  bones  increase  rapidly  in  length  and  in  girth.  As  an  instance  of 
the  unreliability  of  chronologic  age  can  be  cited  the  term  puberty, 
a  physiologic  condition  which  is  supposed  to  occur  at  a  certain 
chronologic  age.  According  to  Crampton's  admirable  work  on 
this  subject,  the  age  at  which  puberty  in  a  group  of  children  of  the 
same  chronologic  age  and  of  either  sex  is  attained  as  expressed  by 
years  is  fallacious,  and  indeed  practically  so  variable  as  to  amount 
to  nothing.  In  a  large  number  of  healthy  boys  varying  from  ten 
to  fifteen  years  the  time  of  pubescence  showed  such  a  variation  that 
Crampton  claims  that  the  growth  of  pubic  hair  indicates  pubescence 
much  more  exactly  and  with  far  less  differences  of  time  than  has 
been  supposed  to  have  been  shown  by  stated  years.  In  like  manner 
Crampton  has  shown  that  the  menstrual  function  of  girls  varies  to 
a  far  greater  extent  in  years  than  it  does  when  reckoned  by  his 
physiologic  sign  of  pubescence.  Crampton  also  shows  that  such 
indications  of  growth  as  height,  weight,  appearance  of  teeth,  and 
strength  seem  to  correlate  quite  closely  with  the  physiologic  signs 
of  pubescence.    These  indications,  as  individual  factors  of  growth, 


52  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

however,  vary  in  the  individual  to  such  an  extent  that  data  taken 
from  them  for  classifj'ing  children  by  years  proves  to  be  inadequate 
and  indeed  incorrect.  Groups  of  boys  of  equal  age  and  in  the  same 
grade  in  school,  their  grades  being  determined  by  their  chronologic 
age,  were  found  to  vary  perhaps  by  a  year  or  a  year  and  a  half,  not 
only  in  their  height,  weight,  strength,  and  in  the  eruption  of  their 
permanent  cuspids  and  second  molars,  but  also  in  their  being  bright, 
moderately  bright,  or  dull.  With  these  results  of  Crampton  before 
us,  it  is  manifestly  absurd  to  place  children  of  the  same  chronologic 
age  necessarily  in  the  same  grade  at  school.  Therefore  some  more 
practical  and  closer  data  for  classification  should  be  sought  for  if 
the  children  are  to  be  intelligently  dealt  with  during  their  school 
years.  Crampton's  work  and  his  deduction  that  the  test  of  the 
growth  of  the  pubic  hair  should  be  made  use  of  in  determining  the 
real  age  of  the  child  are  based  upon  certain  results  which  he  claims 
show  a  much  greater  uniformity  than  does  the  divasion  which  has 
previously  been  made  on  the  basis  of  years.  Some  of  these  results 
are  as  follows : 

Post-pubescents  were  found  to  average  from  24  per  cent,  to  33 
per  cent,  heavier  than  pre-pubescents  of  the  same  age.  Post-pubes- 
cents averaged  as  much  as  11  per  cent,  taller  than  pre-pubescents 
of  the  same  age.  Post-pubescents  averaged  about  33  per  cent, 
stronger  than  pre-pubescents.  The  higher  the  grade  the  fewer  the 
pre-pubescents  for  age,  hence  post-pubescents  are  better  in  scholar- 
ship than  pre-pubescents,  and  the  more  advanced  a  group  is  in 
pubescence  the  better  will  be  the  scholarship.  Crampton  also  con- 
cluded that  by  far  the  greater  part  of  the  correlation  of  weight, 
height,  and  strength  as  found  in  scholarship  was  due  to  the  fact 
that  they  were  all  correlated  in  common  with  the  pubescent  factor. 
Crampton  has  also  concluded  that  earlier  pubescence  favors  good 
scholarship,  later  pubescence  poor  scholarship.    In  a  study  in  regard 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  53 

to  the  eruption  of  the  teeth  in  about  one  thousand  elementary  school 
boys  from  ten  to  fifteen  years  of  age  it  was  found  that  the  appear- 
ance of  the  teeth  had  but  a  slight  relation  to  the  actual  chronologic 
age.  It  was  also  found  that  those  boys  who  had  a  full  set  of  per- 
manent cuspids  averaged  from  five  to  seventeen  pounds  heavier, 
and  from  one  inch  to  three  inches  taller  than  those  with  none.  A 
preliminar}'  study  of  weight,  height,  and  strength  showed  that  men- 
struees  are  taller,  heavier,  and  stronger  than  non-menstruees,  and 
that  weight  showed  the  closest  correlation.  These  investigations 
of  Crampton's  have  been  based  upon  a  period  of  j^ears  from  nine 
to  sixteen  or  seventeen,  and  on  such  physiologic  data  as  could  be 
deduced  from  observations  during  the  pubescent  period.  Although 
certain  investigators  (Marro,  "La  Puberte")  had  already  suggested 
that  the  growth  of  the  axillar}^  and  of  the  pubic  hair  was  significant  as 
showing  physiologic  periods,  yet  such  extensive  investigations  as 
Crampton's  had  not  been  carried  out  pre\dous  to  his  publications, 
and  he  was  the  first  one  to  present  the  thesis  that  all  our  treatment 
of  the  child,  whether  educational,  medical,  or  sociologic,  should 
be  based  upon  physiologic  age  rather  than  upon  chronologic  age. 
Deductions  made  from  the  observations  of  such  external  appearances 
as  the  pubic  hair  must  necessarily  not  represent  very  short,  and  in 
that  sense  practical,  intervals  for  the  purposes  of  classification  of 
which  I  have  just  spoken.  It  has  therefore  seemed  to  me,  allowing 
for  the  present  that  a  correlation  of  physiologic  and  anatomic  condi- 
tions may  be  taken  for  granted,  that  a  study  of  the  anatomic  condi- 
tions present  from  birth  to  thirteen  or  fourteen  years  may  be  of  still 
greater  value  than  the  physiologic  data  based  on  the  observation 
of  the  pubic  hair.  If  such  an  anatomic  classification  can  be  made 
it  will  make  no  difference  in  its  practical  application  whether  the 
individual  child  is  healthy  or  unhealthy,  normal  or  abnormal,  or  is  of 
one  race  or  of  another.    It  may  be  of  a  parentage  differing  in  physical 


54  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

development,  excepting  in  so  far  as  boys  and  girls  can  be  separated 
normally  in  their  anatomic  development.  That  is,  with  such  an 
anatomic  classification  we  can  practically  work  out  our  problems  of 
child  life  irrespective  of  whether  the  individuals  are  boys  or  girls, 
and  whether  the  girls  menstruate  early  or  late.  This  anatomic 
classification  also  is  valuable  for  the  purpose  of  adapting  children 
from  birth  to  adolescence  to  their  proper  healthy  surroundings  and 
to  a  life  suited  to  their  individual  strength  and  capacity.  In  order 
to  prepare  for  and  clear  the  ground  for  the  study  of  this  question, 
namely,  how  to  determine  the  normal  condition  of  young  human 
beings  from  birth  to  thirteen  or  fourteen  years  of  age,  certain  pre- 
liminary investigations  are  necessary. 

With  this  end  in  view  I  have  had  over  two  hundred  children,  who 
according  to  our  previous  ideas  should  be  considered  normal  in  the 
different  years  of  Ufe,  examined  carefully.  In  order  to  obtain  the 
required  data  the  hygienic  surroundings  were  investigated.  It  was 
noted  whether  the  child  was  bright  or  dull  mentally,  what  its  general 
condition  was  with  regard  to  its  appearance,  its  various  functions,  and 
its  appetite,  and  what  diseases,  if  any,  it  had  had  previous  to  the 
time  of  its  examination.  Its  age  was  noted;  at  what  age  it  sat, 
stood,  and  walked  alone,  and  a  record  of  its  weight  and  height  made. 
If  a  girl,  whether  the  catamenia  had  appeared ;  at  what  age,  at  what 
intervals,  and  with  what  regularity;  also  at  what  age  the  mammae 
began  to  develop  and  their  present  condition.  The  circumference 
of  the  head  was  noted,  and  also  any  information  which  could  be 
obtained  as  to  the  closure  of  the  fontanelle,  and  at  what  time  the 
first  dentition  began;  whether  the  temporary  teeth  had  appeared 
at  regular  intervals;  when  the  second  dentition  began,  and  whether 
it  was  being  carried  on  regularly.  A  Roentgenograph  was  then 
taken  of  the  carpal  bones  and  the  child  was  chissified  and  placed 
in  the  division  to  which  the  bones  of  its  wrist  corresponded.    Roent- 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  55 

genographs  were  taken  of  those  children  only  who  were  shown  by 
examination  to  be  presumably  normal  in  their  general  development. 

This  mass  of  data  can  be  used  for  still  further  study  of  the 
correlation  of  weight,  height,  teeth,  chronologic  age,  physiologic 
age,  and  various  external  evidences  of  normal  development  as  shown 
in  the  records.  It  is  my  intention  in  the  future  to  continue  the 
study  of  early  life  on  these  lines  in  order  to  determine  what  correla- 
tion there  is  between  all  these  different  factors  of  the  problem  and 
the  results  which  I  have  obtained  from  my  investigations  of  anatomic 
age.  As  there  can  be  but  little  doubt  that  normal  physiologic  age 
corresponds  closely  to  normal  anatomic  age,  it  seems  to  me  safe 
and  warranted  to  assume  that  Crampton's  physiologic  investigations 
correlate  closely  with  anatomic  normal  development. 

In  undertaking  to  classify  the  different  periods  of  early  life  on 
an  anatomic  basis,  which  will  be  of  practical  use  in  athletics,  in 
school,  and  for  questions  relating  to  child-labor,  it  is  e\'ident  that 
some  reliable  anatomic  standard  representing  the  entire  phj-sical 
development  should  be  found.  It  is  also  important  that  such  an 
anatomic  standard  should  be  readily  obtained,  and  should  be  deter- 
mined in  the  li\'ing  child  with  the  least  degree  of  complexity  and 
in  the  most  simple  form  possible.  In  the  study  of  over  a  thousand 
cases  of  healthy  children  at  the  Children's  Hospital  by  means  of 
the  Roentgen  method  our  Roentgenologist,  Dr.  A.  W.  George, 
found  that  the  most  practical  and  reUable  index  of  development 
was  represented  by  the  hand  and  wrist.  It  is  true  that  various 
changes  which  progressively  take  place  in  the  development  of  the 
shoulder,  elbow,  knee,  and  ankle  are  possibly  somewhat  finer  than 
those  of  the  wrist.  For  the  purpose,  however,  of  obtaining  a  practical 
and  rapid  knowledge  of  the  progressive  normal  changes  which  take 
place  at  different  periods  of  child  life,  the  parts  just  enumerated 
do  not  compare  with  what  can  be  accurately  acquired  in  a  few 


56  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

seconds  from  the  wrist  and  hand.  It  has  occurred  to  me  therefore 
that  a  careful  study  of  the  normal  anatomic  conditions  present  in 
the  bones  of  the  hand  and  wrist  during  different  stages  of  their 
development  would  best  aid  us  in  classifjang  the  different  stages  of 
development,  and  having  formulated  such  a  classification  wo  could 
then  apply  it  practically  to  physical  and  educational  problems. 
IXu'ing  the  last  three  j^ears  I  have  therefore  had  made  careful  studies 
of  a  large  number  of  apparently  healthy  infants  and  children  of 
different  chronologic  ages.  A  record  has  been  kept  of  each  of  these 
children,  not  only  as  to  their  age,  weight,  height,  teeth,  general 
physiologic  and  anatomic  condition,  and  social  surroundings,  but 
also  a  special  record  of  the  development  of  their  hands,  by  means 
of  the  Roentgen  method.  As  a  result  of  these  investigations  it  has 
been  made  very  evident  how  unreliable  are  chronologic  records  in 
regard  to  weight,  height,  and  teeth,  the  teeth  especially  showing  the 
greatest  variations.  I  shall  not  here,  except  in  a  general  way,  refer 
to  the  information  which  I  have  obtained  regarding,  for  instance, 
the  weight  and  height  in  reference  to  the  chronologic  age,  since  the 
unreliability  of  such  correlation  has  often  been  shown  by  other 
investigators.  I  have,  however,  chosen  for  my  classification  only 
those  individuals  who  by  careful  examination  could  be  presumably 
considered  normal.  It  must  be  understood  that  I  am  no  longer 
dealing  with  stages  of  development  as  represented  by  years,  but 
that  my  divisions  are  placed  under  letters.  Having  taken  perhaps 
ten  or  a  dozen  children  of  each  age  chronologically  I  have  then 
placed  them  under  their  respective  anatomic  stages  of  development, 
designating  these  stages  by  A,  B,  C,  D,  and  so  forth.  I  have  then 
used  these  different  stages  for  purposes  of  grading  for  kindergarten, 
for  school,  for  athletics,  and  for  child-labor.  In  a  general  way  in 
making  up  these  alphabetical  groups  I  have  arbitrarily  assumed 
that  the  appearance  of  the  carpal  bones  and  of  the  lower  epiphyses 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  57 

of  the  radius  and  ulna  should,  according  as  they  developed  early 
or  late,  represent  each  alphabetical  division.  As  none  of  these 
bones  are  normally  present  at  birth,  and  as  the  os  magnum  and 
unciform  bones  appear  in  the  first  year,  I  have  placed  this  group  of 
cases  under  A.  Under  B  I  have  grouped  those  hands  which  show 
the  presence,  in  addition  to  Class  A,  of  the  lower  epiphysis  of  the 
radius.  Again  under  C,  those  which  in  common  with  A  and  B  show 
the  presence  of  the  cuneiform  bone.  The  heads  of  the  metacarpal 
bones  and  the  epiphyses  of  the  first  phalanges  at  this  period  can  be 
used  as  controls  of  this  latter  group  C.  Still  under  these  arbitrary 
divisions  I  have  continued  to  place  groups  which  successively  show 
the  presence  of  the  semilunar  and  trapezium  bones  with  the  second 
and  fourth  phalangeal  epiphyses  as  controls  of  this  group.  I 
have  then  introduced  as  additional  groups  those  which  show  the 
scaphoid,  the  trapezoid,  the  lower  epiphysis  of  the  ulna,  and  the 
pisiform  bones.  These  primary  divisions  are  shown  in  Table  4  and 
this  table  can  be  used  as  a  key  by  which  we  can  show  under  which 
alphabetical  division  an  especial  case  should  be  placed.  This  is 
accomplished  by  Roentgenographs  showing  a  picture  of  such  indi- 
vidual carpal  bones  and  epiphyses.  It  is  fortunate  that  the  carpal 
bones  and  the  lower  epiphyses  of  the  radius  and  of  the  ulna  furnish 
a  progressive  series  of  anatomic  development  year  by  year,  so  that 
only  in  unusual  cases  will  it  be  necessary  to  refer  to  the  other  epiphy- 
ses of  the  skeleton  for  the  purpose  of  corroboration. 

Table  4. — Key  to  Index  Development.    Represents  in  Alphabetical  Divisions 
THE  Developmental  Stages  op  the  First  14  Years  op  Life. 

A 

Plate  28 Girl,  6  months 

Os  magnum  and  unciform  bones. 

B 

Plate  29 Girl,  2?  yeare 

Os  magnum,  unciform,  and  lower  epiphysis  of  radius. 


58  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

C 

Plate  30 Girl,  2J  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneiform. 

D 

Plate  31 Boy,  2}  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneiform, 
semilunar. 

Plate  32 Girl,  SJ  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneifonn, 
Bemilunar,  trapezium.  (According  to  Pryor,  scaphoid  should 
come  after  semilunar.) 

Plate  33 Girl,  5J  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneiform,  .semi- 
lunar, trapezium,  scaphoid.  (According  to  Pryor,  trai)ezoid 
should  come  after  scaphoid.) 

G 

Plate  34 Girl,  6J  years 

Os  iiiagiHun,  unciform,  lower  epiphysis  of  radius,  cuneiform,  semi- 
lunar, trapezium,  scaphoid,  trapezoid.  (According  to  Pryor, 
trapezium  should  come  after  trapezoid.) 

H 

Plate  35 Girl,  6  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneiform, 
semilunar,  trapezium,  scaphoid,  trajjczoid,  lower  epiphysis  of  ulna. 

/ 

Plate  36 Girl,  6}  years 

Same  number  of  bones  as  H  but  more  developed. 

/ 

Plate  37 Girl,  SJ  years 

Same  number  of  bones  as  /  but  more  developed. 

A' 

Plate  38 Girl,  Hi  years 

Same  number  of  bones  as  ./,  except  that  possibly  the  pisiform  is 
beginning  to  show  through  the  cuneiform.  The  carpal  bones  also 
are  massing  together  closer  than  in  J,  which  is  significant  of  a 
more  advanced  development. 

Plate  39 Girl,  llf  years 

Os  magnum,  unciform,  lower  epiphysis  of  radius,  cuneiform,  semi- 
lunar, trapezium,  scaphoid,  trapezoid,  lower  epiphysis  of  ulna. 
Pisiform  seen  coming  out  from  under  the  cuneiform. 

M 

Plate  40 Boy,  13J  years 

Same  number  of  bones  as  L,  but  all  the  bones  are  larger  and 
closer  together,  and  the  entire  hand  shows  a  much  greater  and 
later  development  than  any  of  the  other  indices.  Pisiform  bone 
almost  as  large  as  cuneiform. 

In  pursuing  this  investigation  I  have  allowed  for  what  appeared 
to  be  marked  variations  from  the  normal  development.  I  have 
made  my  divisions  irrespective  of  deviations,  by  grouping  those 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  59 

cases  together  which  were  manifestly  in  about  the  same  stage  of 
development  in  the  large  majority  of  cases.  I  am  aware  that  the 
divisions  which  I  have  made  may  have  to  be  subsequently  changed 
according  as  further  investigations  are  carried  out  in  this  Une  of 
study.  In  order,  however,  to  formulate  and  start  what  I  think  in 
the  future  will  be  found  to  be  of  great  aid  in  dealing  with  the  early 
years  of  life,  both  anatomic  and  physiologic,  it  was  necessary  to 
begin  by  arbitrarily  suggesting  groups  of  classifications  as  they 
appeared  to  my  eye  to  show  uniformity.  Some  rather  interesting 
observations  in  this  connection  have  already  come  under  my  notice. 
For  instance,  hands  may  be  long  or  short,  broad  or  narrow,  and  yet 
the  Roentgenograph  will  show  that  they  may  have  the  same  degree 
of  anatomic  development,  showing  also  that  they  should  be  classed 
together  in  one  group.  In  making  up  such  a  group,  however,  we 
cannot  be  guided  except  to  a  limited  degree  by  the  external  appear- 
ances of  the  hands.  I  have  also  noted  in  my  study  of  these  two 
hundred  hands  that  although  there  may  be  a  large  hand,  with  large 
bones,  as  shown  by  the  Roentgen  picture,  yet  this  does  not 
necessarily  imply  advanced  development,  for  the  development  of 
these  large  bones  need  not  necessarily  be  great.  I  have  noted 
also  that  the  normal  appearances  shown  in  Roentgenographs  of 
the  hands  of  boys  and  girls  do  not  materially  differ,  and  that 
the  left  hand  does  not  show  any  difference  in  development  from 
the  corresponding  right  hand.  In  all  probability  it  will  be  found 
that  many  of  the  statements  which  have  been  made  in  the  dif- 
ferent anatomies,  which  are  the  results  of  investigations  on  dead 
subjects,  will  be  proved  eventually  to  be  incorrect  when  sub- 
mitted to  the  more  exact  observations  which  can  be  carried  out 
on  the  living  subject.  Notably  one  of  these  discrepancies  is  that 
in  a  number  of  anatomies,  English,  French,  and  German,  the  lower 
epiphysis  of  the  ulna  has  been  placed  as  early  as  two  and  a  half 


60  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

years,  three  years,  four  years,  and  five  years.  The  appearance  of 
this  epiphysis  in  my  cases,  however,  was  found  to  be  very  rare  before 
the  sixth  year,  and  it  usually  began  to  appear  in  division  //,  where 
the  children  were  from  six  to  seven  years  old.  It  is  also  to  be 
noted  that  while  the  pisiform  bone  has  been  found  as  early  as  the 
tenth  year,  and  according  to  Porier,  the  eighth  year,  in  none  of  my 
cases  was  it  found  before  the  twelfth  year,  excepting  once  as  an 
anomaly  in  the  eighth  year.  I  have  also  noted  that  the  heads  of 
the  metacarpal  bones  are  not  especially  satisfactory,  so  far  as  classi- 
fication is  concerned,  and  should  therefore  be  used  more  as  con- 
trols in  cases  where  the  development  of  the  wrist  is  not  sufficiently 
conclusive. 

In  order  to  represent  this  classification  practically  we  should 
have  pictures  which  represent  the  development  of  the  special  group 
before  us,  and  using  these  for  comparison  determine  an  individual 
child's  anatomic  age.  These  pictures  I  have  prepared,  choosing 
them  as  representative  of  their  especial  group.  It  is  very  evident, 
if  this  system  of  grading  children  in  the  future  proves  to  be  correct 
and  useful,  that,  except  legally,  we  should  no  longer  think  in  years 
and  months,  but  in  normal  anatomic  groups  A,  B,  C,  and  so  on. 
We  should  remember  also  that  all  our  physiologic  knowledge  should 
be  brought  to  bear  on  this  subject,  using  it  in  conjunction  with, 
and  as  a  control  on,  our  anatomic  knowledge;  also  that  in  doubtful 
cases  the  development  of  other  parts  of  the  skeleton,  such  as  the 
shoulder,  elbow,  hip,  knee,  ankle,  and  foot,  should  be  used  as  controls. 
We  might  indeed  say  that  it  is  the  sum  total  of  all  our  physiologic 
knowledge,  together  with  that  of  the  development  of  the  entire 
skeleton  and  the  different  organs,  which  tells  us  exactly  how  to 
solve  the  many  problems  of  early  life.  For  preliminar>'  information, 
however,  on  these  points  we  should  first  turn  to  what  seems  to  be 
the  most  reliable  index,  namely,  the  wrist.    These  groups  of  course 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  61 

are  manifestly  somewhat  arbitrary,  and  depend  upon  my  observa- 
tion of  such  cases  as  my  experience  has  shown  to  represent  the 
majority  of  normal  conditions  rather  than  variations.  Further 
study  may  prove  that  it  will  be  more  exact  to  adopt  certain  other 
divisions  and  possibly  to  merge  some  of  these  present  divisions  into 
one.  This,  however,  can  easily  be  done  if  we  are  sure  that  the  divi- 
sions are  improved  and  made  more  practical  in  this  way.  What  I 
wish  to  state,  however,  is  that  I  believe  we  are  working  with  the 
right  principle,  and  that  practical  results  in  the  hne  of  perfecting 
the  development  of  children  and  guarding  them  during  the  process 
of  their  development  from  overstrain  both  mentally  and  physically 
can  thus  be  accomplished.  It  may  be  stated  as  a  rule  that,  while 
in  all  probability  weight  and  height  correlate  with  a  stated  stage  of 
normal  anatomic  development,  that  is,  greater  or  less  according  to 
the  anatomic  development,  yet  this  is  true  only  where  a  group 
of  individuals  of  the  same  anatomic  development  are  concerned, 
rather  than  where  the  height  and  weight  are  compared  with  an 
individual  of  a  stated  chronologic  age.  It  is  very  evident,  as  shown 
by  those  who  have  investigated  the  eruption  of  the  teeth,  that  such 
eruption  is  entirely  unreliable  for  purposes  of  classification.  The 
sigma  (range  of  variation)  is  very  great  as  regards  the  eruption  of 
the  teeth  and  the  height  and  the  weight  in  comparison  with  the 
chronologic  age,  which  in  its  turn  shows  a  corresponding  sigma  as 
regards  the  anatomic  conditions. 

The  regulation  of  questions  concerning  the  physical  and  mental 
care  of  the  early  years  of  life  should  be  much  more  under  the  control 
of  the  medical  profession  than  is  now  the  case.  An  intimate  knowl- 
edge of  medical  subjects  and  advanced  medical  training  are  needed 
to  grasp  these  questions  fully  and  to  treat  them  intelligently.  Surely 
it  is  one  of  the  gravest  duties  of  physicians  to  turn  their  attention 
to  all  subjects  connected  with  children,  and  not  to  leave  them  to 


62  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

be  worked  out  by  the  non-professional  laity.  Educators  dealing 
with  these  questions  cannot  accomplish  what  they  are  not  by  long 
years  of  physiologic  and  anatomic  study  fitted  for.  The  educator 
in  the  public  schools  in  grappling  with  the  difficult  questions  of 
physical  training  should  work  hand  in  hand  with  the  medical  pro- 
fession, for  thus  only  can  the  great  end  in  view,  of  producing  not 
only  highly  educated  but  healthy  and  vigorous  citizens,  be  attained. 
The  papers  read  in  1908  at  the  Delaware  Water  Gap  by  Abt,  of 
Chicago,  and  by  Kerley,  of  New  York,  on  the  vital  questions  con- 
nected with  kindergarten  and  school  life  show  the  necessity  for 
physicians,  and  especially  for  those  who  are  interested  in  pedi- 
atrics, to  take  at  once  active  measures  to  change  the  unwarrantable 
situation  which  confronts  us  in  our  schools  and  factories.  This 
situation,  with  its  irrational  conditions  and  baneful  results,  is  threat- 
ening to  destroy  the  healthy  bodies  and  minds  of  a  large  majority 
of  our  future  citizens  at  the  very  beginning  of  their  careers.  It  is 
giving  them  as  preparatory  for  their  race  in  life  the  handicap  of  a 
weak  and  easily  strained  physique  and  an  overtaxed  brain,  at  the 
very  period  of  development  when  it  tells  most  severely.  I  say  this 
with  a  full  understanding  of  how  great  is  the  recuperative  power 
of  the  young.  There  are  certain  overstrains,  however,  which  can 
never  be  eradicated,  notwithstanding  this  high  grade  of  recupera- 
tive power.  At  any  rate  we  who  have  the  knowledge  and  wisdom 
of  adults  have  no  right  to  subject  millions  of  ignorant  and  helpless 
young  human  beings  to  a  system  of  living  which  is  disastrous  to  the 
majority.  We  also  have  no  right  in  connection  with  this  phase  of 
life  to  trust  to  the  survival  of  the  fittest.  On  the  contrary  all  these 
young  lives  should  if  possible  be  made  to  be  the  fittest.  Such  being 
our  manifest  duty,  any  means  by  which  we  can  judge  in  the  readiest 
way  of  the  physical  and  mental  conditions  of  the  individual,  and  in 
this  sense  to  care  for  and  treat  him  personally  according  to  his  indi- 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  63 

vidual  needs,  should  be  sought  for.  If  it  is  decided  that  by  the  Roent- 
gen method  applied  to  the  hand,  young  human  beings  can  be  classified 
as  individuals,  it  becomes  a  simple  matter  for  the  State  or  city  by 
means  of  a  Roentgen  ray  apparatus  to  rapidly  make  preliminary 
examinations.  They  can  then  classify  physical  conditions  and  the 
usually  correlating  brain  \'igor,  for  this  can  easily  be  done  in  an 
individual  in  less  than  a  minute.  In  regard  to  the  classification  of 
young  children  for  kindergarten,  it  is  well  known  that  in  Massa- 
chusetts children  may  enter  the  kindergarten  at  from  three  and  a 
half  to  five  years  of  age  and  remain  there  for  two  years.  They  are 
then  advanced  to  the  first  school  grade,  and  thence  through  the  suc- 
cessive grades  to  the  ninth  grade,  from  which  they  are  graduated 
to  the  high  school.  Special  localities  have  variations  from  this  rule. 
In  Melrose,  for  instance,  children  must  be  five  years  old  before  they 
are  allowed  to  enter  school.  In  the  first  year  of  their  teaching  they 
take  partly  kindergarten  work  and  partly  work  of  the  first  grade. 
The  next  year  they  take  the  work  of  the  first  and  second  grades,  so 
that  when  they  enter  the  third  grade  they  have  an  equal  standing 
with  those  of  other  third-year  grades.  By  classifying  young  children 
according  to  their  anatomic  rather  than  to  their  chronologic  age, 
we  do  away  with  the  necessity  for  diverse  rules.  By  grouping  them 
according  to  their  physical  conditions  we  avoid  the  overstrain  of 
both  body  and  mind  which  arises  from  making  them  compete 
mentally  with  their  stronger  and  more  vigorous  companions  of 
equal  chronologic  age.  This  same  method  and  this  same  idea  should 
be  carried  out  in  the  various  school  grades  when  a  preliminary  sifting 
and  placing  of  the  children  is  undertaken.  To  those  who  in  reply 
to  this  would  ask  what  is  to  be  done  with  the  precocious  and  bright 
children  who  are  intellectually  superior  to  their  companions  of 
equal  chronologic  age,  I  would  say  that  I  do  not  beUeve  that  bright 
children  are  dealt  with  as  thev  should  be  or  as  is  manifestlv  safe 


64  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

for  their  future  welfare.  Both  parents  and  teachers  wish  to  stimulate 
these  bright  children  in  their  studies  and  have  them  graded  with 
groups  of  children  who  are  older  and  are  better  fitted  physically 
to  undergo  school  life  without  overstrain.  According  to  the  physi- 
cian's point  of  view  these  children  when  they  are  found  to  be  behind- 
hand in  anatomic  growth  should  not  be  allowed  to  be  advanced  on 
account  of  their  mental  brightness.  They  should  be  kept  out  of 
doors  as  much  as  possible,  and  special  attention  should  be  paid  to 
their  physical  development  until  such  development  has  shown  the 
normal  conditions  requisite  for  health.  As  to  the  comparatively 
stupid  children  who  present  a  normal  or  even  more  than  normal 
physical  development,  as  shown  by  the  Roentgen  examination, 
they  should  be  allowed  to  find  their  level  in  the  lower  grades  and, 
indeed,  no  great  anxiety  in  regard  to  them  is  called  for.  In  regard 
to  gymnastics  and  athletics  many  a  boy  or  girl  could  by  careful 
anatomic  grading  be  saved  from  the  reactive  debility  which  we  so 
often  see  arise  from  an  unwise  overstrain  of  a  physical  handicap. 
Supposing  we  take  twenty  boys  or  girls  at  random,  except  that 
they  are  all  ten  years  old  chronologically.  If  we  pit  ten  of  these 
individuals  against  the  other  ten,  either  in  football  or  in  basketball, 
we  are  running  the  risk  of  pitting  in  a  contest  of  strength  ten  individ- 
uals who  may  be  only  eight  and  a  half  or  nine  years  old  against  ten 
who  may  be  eleven  or  eleven  and  a  half  years  old.  Such  a  variation 
in  chronologic  age  is  found  when  we  classify  chronologically  instead 
of  using  the  anatomic  standard  which  would  pit  ten  against  the 
other  ten  in  such  a  way  that  the  contestants  would  be  of  equal 
physique,  which  means  equal  anatomic  age  and  the  least  likelihood 
of  overstrain. 

Finally,  in  regard  to  the  question  of  child-labor,  it  is  certainly 
the  duty  of  physicians  to  join  hand  in  hand  with  educational.  State, 
and  city  authorities  to  prevent  children  from  being  allowed  to  work, 
excepting  under  certain  physical  conditions. 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  65 

I  have  already  shown  that  a  child  may  be,  so  far  as  chronologic 
age  is  concerned,  of  the  age  demanded  by  the  law  for  child-labor, 
especially  in  factories.  These  laws  of  chronologic  age  differ  in  differ- 
ent States,  and  in  some  of  the  States  there  is  not  much  to  be  found 
fault  with  in  respect  to  the  law.  In  others,  however,  the  law  permits 
children  to  begin  work  in  the  factories  at  entirely  too  early  an  age. 
I  shall  not  discuss  this  question  of  child-labor  very  much  in  detail, 
as  it  is  too  broad  a  subject.  There  are,  however,  certain  facts  con- 
nected with  the  determination  of  the  child's  physical  condition 
which  should  manifestly  be  referred  to  here.  In  the  first  place, 
we  know  that  a  child  may  be  only  eleven  years  old  and  yet  look  as 
though  it  were  twelve  or  thirteen.  In  like  manner,  in  my  investiga- 
tions, I  have  found  that  a  child  may  be  thirteen  years  old  and  yet 
have  only  the  normal  anatomic  development  of  eight  years.  This 
means  that  although  it  has  the  age  of  a  child  which  would,  according 
to  the  laws  of  certain  States,  allow  it  to  work  in  the  factories,  yet, 
really,  it  is  absolutely  unfitted  to  do  so. 

It  may  be  said,  of  course,  that  these  cases  are  rare.  It  is,  how- 
ever, manifestly  important  to  detect  them  when  they  present  them- 
selves. That  is,  the  individual  should  be  examined  to  see  whether 
physically  and  physiologically  he  or  she  is  fitted  for  work  in  the 
factories  or  elsewhere,  and  not  trust  to  chronologic  age,  which  may 
differ  by  a  year  or  a  year  and  a  half  from  anatomic  age. 

It  is  not  always  the  fault  of  those  who  employ  children  in  the 
factories  or  elsewhere,  as  it  often  rests  in  the  hands  of  the  parents 
themselves.  For  instance,  if  a  girl  is  tall  and  looks  older  than  she 
really  is,  the  parents  are  very  apt  to  wish  to  make  her  earn  wages 
for  the  support  of  the  general  household.  Under  these  circum- 
stances, over  and  over  again,  they  will  say  that  the  child  is  as  old 
as  she  looks,  and  not  tell  the  truth  about  her  actual  age.  Again, 
often  among  the  poorer  classes  in  the  South,  the  parents  do  not 

5 


66  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

always  know  exactly  how  old  the  children  are,  as  they  may  have 
forgotten.  This  not  infrequently  happens.  How  is  the  State  law 
to  be  carried  out  justly  when  it  is  so  handicapped  by  the  ignorance 
and  the  lack  of  veracity  of  the  parents,  confirmed,  under  certain 
circumstances,  by  the  outward  appearance  of  the  individual  child? 
Manifestly,  we  should  have  some  standard  which  does  not  depend 
upon  veracity,  intelligence,  memory,  greed,  or  external  appearances. 
This  can  be  accompUshed  by  means  of  the  Roentgen  method,  which 
always  tells  the  truth,  and  is  an  open  book  to  those  who  have  learned 
to  read  its  language.  The  simplicity  of  the  method,  merely  to  have 
a  child  for  a  second  put  its  hand  on  a  table  and  have  it  pictured  by 
the  Roentgen  ray  on  a  plate,  without  harm  and  without  the  slightest 
danger,  must  recommend  it  to  all  intelligent  educators  and  to  State 
officials.  Physicians  well  know  how  important  an  aid  to  our  medical 
armamentarium  is  the  Roentgen  method  of  examination. 

In  the  following  table,  No.  5,  I  have  brought  together  some 
of  the  chronologic  ages  which  I  have  extracted  from  the  report  of 
the  Industrial  Commission  on  Labor  Legislation,  Vol.  V,  Boston 
Public  Library,  933L073. 


Table  5. — State  Laws  Regarding  Child-labor. 

Nebraska  * 
10  years. 


New  Hampshire 
Vermont 
.  California 

In  South  Carolina  if  the  parents  are  dependent  children  are  allowed  to  work  in 
the  mills  when  they  are  10  years  old. 

Maine 

Rhode  Island 
Wisconsin 

12  years Maryland 

West  Virginia 
North  Dakota 
Tennessee 

f  New  Jersey  t 
12  to  14  years |  Louisiana 

•  Children  under  12  years  of  age  can  work  only  4  moDths  in  the  year, 
■t  Girls,  12;  boys,  14. 


14  years. 


ILLUSTRATIVE  USE  OF  LIVING  NORMAL  ANATOMY.  G7 

13  years (Pennsylvania 

\  Ohio 

Massachusetts 
Connecticut 
New  York 
Indiana 
Illinois 
Michigan 
Missouri 
Minnesota 
Colorado 
.  Dist.  of  Columbia 

The  employment  of  children  under  a  certain  age  is  absolutely 
forbidden  in  factories.  The  law  also  limits  their  employment  in 
various  forms  of  labor,  with  a  view  to  their  education  in  the  public 
schools.  It  accomplishes  this  by  restricting  it  unless  they  have 
certain  educational  qualifications,  or  by  requiring  licenses  from  the 
truant  officers,  factory  inspectors,  boards  of  health,  or  other  persons 
before  they  can  be  employed  in  factories  at  all. 

Looking  at  this  list  of  those  who  can  endorse  child-labor,  we 
are  at  once  struck  with  what  an  immense  number  of  loop-holes 
may  be  present  by  which  the  law  of  the  various  States  can  be  evaded. 

It  is  significant,  however,  in  how  many  States  the  law  is  placed 
at  twelve  years,  and  still  more  in  those  which  place  it  at  ten.  Prob- 
ably in  some  of  the  Southern  States  children  are  allowed  to  labor 
in  the  mills  at  a  still  earlier  chronologic  age. 

It  would  seem  that  the  influence  of  the  medical  profession 
should  be  brought  to  bear  more  than  it  ever  has  before  on  this  sub- 
ject. As  a  safeguard  to  the  health  of  the  children  throughout  the 
States,  commissioners  should  be  appointed  who,  by  their  training 
as  physicians  and  caretakers  of  early  life,  can  inform  the  State  at 
what  period  of  development  it  is  safe  to  allow  child-labor  to  begin. 

Of  course  a  much  further  study  of  the  carpal  bones  and  of  the 
epiphyses  of  the  radius  and  of  the  ulna  must  be  made  before  we 


68  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

conclude  what  are  to  be  considered  and  can  be  recognized  as  varia- 
tions or  anomalies.  This,  however,  I  believe  is  possible  if  a  number 
of  Roentgenologists  and  physicians  throughout  the  country  pay 
attention  to  this  anatomic  question.  Of  course  such  physiologic 
observations  as  Crampton  has  placed  before  us  will  aid  very  much 
in  the  determination  of  anatomic  age  by  means  of  the  anatomic 
development  of  the  wrist. 

In  bringing  before  the  medical  profession  this  idea  of  using  the 
Roentgen  method  for  physical  and  mental  classification,  I  wish  it 
to  be  understood  that  I  am  merely  asking  it  to  endorse,  and  educator 
to  make  trial  of,  what  seems  a  probable  means  of  doing  justice  to 
young  human  beings. 

I  have  had  to  make  arbitrary  divisions,  and  these  divisions 
should  be  studied  and  careful  work  of  verification  or  refutation 
carried  out  on  these  lines.  Such  work,  however,  I  believe  to  be 
worthy  of  trial,  as  if  successful  it  simplifies  the  whole  question  of 
the  guidance  of  child  life,  and  wards  off  the  dangers  resulting  from 
our  present  ill-advised  management  of  the  whole  subject. 


I'LATK  2S. 
CROIP  A.     NORMAL. 

Girl,  age  (i  months. 

Os  mamiuiin  iind  unciform  l)onc's  arc  present;   no  epiphyses 
have  developed. 


Pirate  28 


.^, 


J-k. 


PLATE  29. 

GROrP  B.    XORMAL. 

Girl,  age  2J  years. 

Os  niafinvim,  uncifonn,  and  lower  epiphyses  of  radius. 

There  are  also  present  the  epiphysis  of  the  thumb  (proxi- 
mal) and  the  epiphyses  of  the  di.stal  ends  of  the  sceond,  third, 
fourth,  and  fifth  metacarpal  bones;  also  the  epiphyses  (proxi- 
mal) of  the  first  phalanges,  and  a  very  sliglit  indication  of  the 
epiphysis  of  the  distal  phalanx  of  the  thumb,  and  also  a  faint 
indication  of  the  epiphysis  (proximal)  of  the  fourth  phalanx. 
The  other  phalanges  are  obscui'ed  by  the  fingers  of  the  attend- 
ant's hand  which  was  restraining  the  infant's  hand. 


Pjlatk  29 


PLATE  30. 
GROUP  C.    NORMAL. 

Girl,  age  23  years. 

The  OS  magnum,  unciform,  lowor  epiphysis  of  radius  and 
cuneiform  are  present. 

The  epiphyses  of  all  the  metacarjial  bones  and  of  the  pha- 
langes have  appeared  excepting  the  proximal  epiphysis  of  the 
distal  phalanx  of  the  first  finger  and  of  the  fifth. 


Plate  30 


PLATE  31. 
GROUP  D.    NORMAL. 

Boy,  BKe  2i  years. 

The  08  nuifimiin,  unciform,  lower  cpiijhysis  of  radius,  cunci- 
forni,  ami  semilunar  are  present. 

All  the  epiphyses  of  the  metacarpal  bones  and  of  the  i)ha- 
langes  have  appeared  excepting  the  distal  phalanges  of  the  first 
and  fifth  fingers.  The  proximal  epiphyses  of  the  metacarpal 
bones  and  first  phalanx  of  the  thvinib  are  scarcely  perceptible. 


Plate  31 


\ 


TLAT]-:  32. 
GROUP  E.  NORMAL. 

Girl,  age  3^  years. 

The  OS  niaiiiHini,  unciform,  lower  epiphysis  of  the  radius, 
cuneiform,  semihmar,  and  trapezium  are  present. 

All  the  epiphyses  of  the  metacarpal  bones  and  of  the  pha- 
langes are  present. 

The  arrowhead  points  at  what  is  presumaMy  the  trapezium 
or  the  trapezoid,  which  with  the  scaphoid  seem  at  times  to  be 
interchanjjeablc. 


Platk  32 


PLATE  33. 
GROUP  Y.    NORMAL. 

Girl,  age  oi  year.-.. 

The  OS  maiinum,  unciform,  lowor  epiphysis  of  the  radius, 
cuneiform,  semilunar,  trapezium,  and  seaplioid  are  present. 
.4..  Points  to  tlie  trapezium  or  i)ossibly  aeeording  to  Pryor  to 

the  trapezoid. 
B.  Points  to  the  scaphoid. 

All  th<'  epiphyses  of  the  metacarpal  bones  and  of  the  pha- 
langes are  present. 


Plate  33 


PLATE  34. 
GROUP  (;.    NORMAL. 

Girl,  age  Gi  years. 

The  OS  magnum,  unciform,  lower  epiphy.sis  of  the  radius, 
cuneiform,  scmihinar,  trapezium,  scaphoid,  and  trapezoid  are 
present. 

All  the  epiphyses  of  the  metacarpal  bones  and  of  the  pha- 
langes are  present. 


Plate  34 


PLATK  3."). 
GROUP  H.    XOKMAL. 

Girl,  age  G  year.-i. 

The  OS  magnum,  uncif(jrm,  lower  epiphysis  of  the  radius, 
cuneiform,  semilunar,  trapezium,  scaphoid,  trapezoid,  and  also 
the  lower  epiphysis  of  the  ulna  arc  present. 

All  the  epiphyses  of  the  metacarpal  bones  and  of  the  pha- 
langes are  present. 

Note  the  beginning  of  the  massing  between  the  trapezium 
and  trapezoid. 


PXiATE  35 


■;^^^J 


PLATE  ;3G. 
GROUr  I.    NORMAL. 

Girl,  aiie  fij  y('ar>. 


Same  as  Group  H  as  to  nunihcr  of  hones,  hut  much  more 
adviiiiccd  in  (Icvclopincnt  and  more  advanced  as  to  massing. 


Plate  ;JG 


PLATE  37. 
GROUP  J.    NORMAL. 

Girl,  age  SJ  years. 

Same  a.s  Group  1,  but  more  advanced  in  development. 


PliATE  37 


PLATI':  3S. 
GROUP  K.  NORMAL. 

Girl.  :ij;e  Hi  years. 

Same  a?  Group  .1,  but  tho  pisiform  bone  has  appeared  under 
the  cuneiform,  and  all  the  carpal  bones  and  epiphy.-;es  are  much 
more  massed  and  further  advanced  in  development. 

Xote  marked  advance  in  develoimient  of  .-tyloid  ])r<)cess  of 
lower  epiphysis  of  the  ulna. 


Platk  38 


PLATE  39. 
CliorP  L.    XORMAL. 

Girl,  age  llj  years. 

Same  iis  Group  K.  but  more  advanced  in  development.  The 
pisiform  bone  appears  plainly  at  the  lower  end  of  the  cuneiform. 

The  arrow  points  to  the  pisiform  bone. 

Note  the  advanced  development  and  the  process  of  ossifica- 
tion bepinnin.n-  between  the  lower  epiphyses  of  the  radius  and 
ulna  with  their  diaphyses. 


Plate  39 


"*^"'^ 


PLATE  40. 
GROUP  M.    NORMAL. 

Boy,  age  13i  years. 

Same  as  Group  L,  but  verj^  much  more  advanced  in  develop- 
ment, and  the  pisiform  bone  almost  as  much  so  as  the  cuneiform. 
The  arrow  points  to  the  pisiform  bone. 


Plate  40 


Division  III 

DISEASES  OF  THE  NEW-BORN 

By  diseases  of  the  new-born  we  mean  such  abnormal  conditions 
as  have  occurred  in  intra-uterine  life  and  are  present  at  birth  and 
in  the  early  days  of  Ufe.  All  these  diseases,  whether  acquired  in 
intra-uterine  life  or  at  the  time  of  birth,  depend  in  most  cases  on 
the  great  role  which  is  played  by  development  in  its  various  stages. 
It  is  this  developmental  class  which  almost  entirely  represents  the 
diseases  of  the  new-born  which  can  be  shown  by  the  Roentgen 
method  of  examination.  It  is  well  known  that  the  growing  tissues 
are  more  vulnerable  and  their  power  of  resistance  less  when  their 
complete  development  has  not  taken  place.  The  tissues  of  early 
life  are  open  not  only  to  specific  infections,  but  to  numberless  as 
yet  undifferentiated  varieties  of  pathogenic  microorganisms  which 
are  but  little  understood.  The  effects,  however,  which  these  organ- 
isms have  upon  the  normal  growth  of  the  various  tissues  and  the 
abnormalities  which  may  result  from  delayed  or  perverted  normal 
anatomic  conditions  are  recognized,  and  these  conditions  are  shown 
in  what  are  called  malformations.  The  Roentgen  examination  of 
certain  malformations  of  the  mouth,  nose,  and  extremities  is  of 
especial  significance  from  a  surgical  point  of  view.  Those  of  especial 
interest  medically  are  malformations  connected  with  the  develop- 
ment of  the  teeth,  heart,  ribs,  stomach,  intestines,  and  liver.  Under 
this  class  come  also  such  conditions  of  arrested  development  as  are 
represented  in  the  bones  where  the  transformation  from  cartilage 
to  bone  has  either  been  arrested  entirely  or  retarded  to  such  an 
extent  that  marked  shortening  will  always  be  present.  The  impor- 
tance of  the  study  of  diseases  of  the  new-born  has  become  more 
marked  since  the  discoverj'^  of  the  Roentgen  ra3^     In  almost  every 

69 


70  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

abnormal  condition  of  this  class  we  can  by  the  Roentgen  method 
determine  the  exact  arrangement  of  the  organs  and  bones,  and  in 
this  way  the  underlying  conditions  of  a  given  deformity  can  be 
made  evident  at  once.  By  means  of  the  Roentgen  method  of  exami- 
nation the  question  of  corrective  measures  and  the  prognosis  in 
regard  to  future  use  are  made  possible.  For  purposes  of  simplicity 
these  abnormal  conditions  can  be  classified  into: 

Anomalies  of  the  head,  spine,  and  ribs. 
Intrathoracic  and  intra-abdominal  diseases. 
Diseases  of  the  extremities  and  pelvis. 
Chondrodystrophia  fcetalis. 
Osteogenesis  imperfecta. 
Fetal  rhachitis. 
Obstetrical  paralysis. 

While  the  number  of  malformations  in  each  of  these  divisions 
is  large  and  represents  definite  abnormal  conditions,  yet  those  which 
can  be  portrayed,  explained,  and  diagnosticated  by  the  Roentgen 
method  are  comparatively  small.  New  and  heretofore  unseen 
anomalies  are  met  with  from  time  to  time,  and  to  collect  all  the 
anomalous  conditions  which  have  been  seen  up  to  the  present  time 
would  require  a  special  work  on  this  subject.  I  shall,  therefore, 
only  speak  in  a  general  way  of  diseases  of  the  new-born  in  order  to 
illustrate  what  great  aid  the  Roentgen  method  of  examination  gives 
us  by  disclosing  what  the  anomalous  condition  may  be.  If  the  dis- 
ease is  surgically  curable  the  picture  shows  us  where  and  how  best 
to  operate.  If  it  be  of  the  class  of  cases  which  are  represented  by 
transposition  of  the  organs,  such  as  the  heart  in  the  thorax  (see  Divi- 
sion VI,  Plate  110),  or  the  hver  and  spleen  in  the  abdomen,  the 
knowledge  of  these  conditions  is  of  infinite  aid.  As  the  child  grows 
older  and  its  development  increases,  the  Roentgen  method  assists  in 


DISEASES  OF  THE  NEW-BORN.  71 

the  diagnosis  of  these  diseases  and  proves  that  the  condition  is  anom- 
alous and  does  not  represent  acquired  disease.  It  is  a  fact  that  it 
is  rare  to  find  two  identical  anomalies  in  two  individuals.  It  is  to 
be  clearly  understood  that  the  classification  which  I  have  just  sug- 
gested is  not  based  on  any  systematic  division  etiologically,  patho- 
logically, or  symptomatically ,  but  is  merely  an  attempt  to  bring  before 
the  student  the  pictures  of  the  various  parts  in  such  a  way  that  he 
can  readily  grasp  their  meaning.  In  studying  a  Roentgenograph  of 
the  entire  skeleton  we  would  naturally  begin  by  examining  the  head, 
and  then  logically  follow  the  picture  down  through  the  spine,  thorax, 
and  upper  extremities,  abdomen,  pelvis,  and  lower  extremities. 

ANOMALIES  OF  THE  HEAD,  SPINE,  AND  RIBS 
HEAD 

The  anomalies  of  the  head  which  can  be  distinguished  at  birth 
by  the  Roentgen  ray  and  classified  under  diseases  of  the  new-born 
are  comparatively  few  in  number.  The  variations  and  anomalies 
of  the  teeth  would  naturally  be  spoken  of  at  a  later  period  of  develop- 
ment when  the  teeth,  whether  unerupted  or  erupted,  play  a  more 
prominent  role  than  is  the  case  at  birth.  They  will  therefore  be 
described  in  Division  V  under  diseases  of  the  head. 

SPINE 

Anomalous  conditions  of  the  vertebrae  may  occur  in  any  part 
of  the  spine,  as  is  seen  in  Plate  41,  which  shows  the  head  and  neck 
of  a  boy  six  years  old  with  a  congenital  anomalous  condition  in  the 
upper  cervical  region.  There  appears  to  be  a  fusion  of  the  atlas 
with  the  base  of  the  skull.  The  axis  also  shows  marked  deformity 
as  compared  with  the  normal  upper  cervical  vertebrae  shown  in 
Plate  27.  The  remainder  of  the  vertebrae  seem  to  be  normal.  The 
child  in  this  case  shows  a  quite  distinct  normal  orbit.    The  frontal 


72  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

sinus  does  not  show  definitely.  The  antrum,  as  would  be  expected 
at  this  age,  is  small  and  ill-defined.  In  the  upper  jaw,  beginning 
in  front,  we  find  all  of  the  temporary  teeth  in  place  normally,  but 
not  clearly  defined  by  individual  markings  up  to  the  first  temporary 
molar.  This  is  due  to  the  angle  at  which  they  were  taken  and  to 
the  consequent  interference  of  the  pictures  of  the  teeth  on  the  oppo- 
site side  of  the  jaw.  The  first  temporary  molar  and  also  the  second 
temporary  molar  show  the  development  of  the  crown  and  root 
plainly.  Immediately  above  the  first  temporary  molar  in  the  alveolus 
can  be  seen  the  tip  of  the  first  bicuspid  becoming  calcified.  The 
second  temporary  molar  shows  plainly  the  characteristic  large  pulp 
chamber  and  the  delicately  pencilled  buccal  roots.  In  the  light 
area  above  the  second  temporary  molar  is  the  crypt  of  the  second 
bicuspid,  but  no  signs  of  calcification  are  seen.  Immediately  back 
of  the  second  temporary  molar  is  the  first  permanent  molar  with 
only  its  crown  calcified.  There  is  no  appearance  of  the  second  per- 
manent molar  or  of  the  third  permanent  molar. 

In  the  lower  jaw  beginning  behind  the  crypt  of  the  second  per- 
manent molar  are  shown  the  buccal  cusps  completely  calcified. 
Directly  in  front  of  the  second  permanent  molar  is  the  crypt  and 
calcified  crown  of  the  first  temporary  molar,  with  its  light  area 
below,  in  which  lies  the  formative  organ  (dental  pulp  or  bud).  An- 
terior to  this  second  temporary  molar  the  pictures  are  indistinct, 
but  probably  represent  normal  temporary  teeth. 

The  spinal  column  may  show  an  absence  of  one  or  more  verte- 
brae, or  an  additional  vertebra,  or  lordosis  or  kyphosis.  The  main 
object  in  view,  however,  is  that  having  seen  one  or  two  illustrative 
cases  we  may  thus  be  able  to  recognize  other  anomalous  conditions 
of  this  nature.  The  condition  of  rhachischisis  is  one  of  the  principal 
forms  of  congenital  defects  of  the  spine,  but  though  a  Roentgeno- 
graph of  this  condition  might  be  interesting  from  an  embryologic 


DISEASES  OF  THE  NEW-BORN.  73 

point  of  view,  the  malformation  is  so  evident  at  birth  that  the 
Roentgen  ray  for  diagnosis  would  be  unnecessary.  It  is  a  disease 
of  pathologic  rather  than  of  clinical  interest,  for  not  only  is  there 
a  deficiency  of  the  vertebral  arches,  but  the  cord  itself  is  rudimentar}\ 
Comparatively  few  anomalies  of  the  vertebrae  have  been  seen  which 
can  be  classed  under  diseases  of  the  new-born  and  are  of  interest 
from  a  Roentgen-ray  point  of  view.  In  the  study  of  each  case  the 
vertebrae  should  be  counted,  and  we  should  note  whether  the  inter- 
vertebral discs  are  distinct,  or  are  compressed,  fused,  or  destroyed. 
The  number  of  vertebrae  may  be  increased  or  diminished,  a  deficiency 
in  one  region  usually  being  replaced  by  an  additional  vertebra  in 
another.  It  is  to  be  noted,  however,  that  the  number  of  bones  in 
the  cervical  region  is  rarelj'  increased  or  diminished.  An  additional 
or  lessened  number  of  vertebrae  in  the  lumbar  region  is  of  especial 
interest  in  connection  with  the  technic  of  lumbar  puncture. 

Spina  Bifida. — The  most  common  disease  of  the  spine  which 
occurs  during  intra-uterine  life  is  spina  bifida.  This  condition  is 
getting  to  be  of  additional  importance,  since  by  means  of  the  Roent- 
gen method  considerable  advances  have  been  made  in  the  treatment 
of  these  cases  through  the  more  precise  diagnosis  which  can  be  at- 
tained by  detecting  the  exact  type,  locality,  and  extent  of  the  lesion 
before  operation.  Spina  bifida  is  a  condition  in  which  there  is  a  fail- 
ure of  closure  of  the  laminae  of  the  vertebrae.  At  certain  intra-uterine 
periods  this  anatomic  condition  is  normal,  but  when  it  is  found  at 
full  term  it  becomes  abnormal  from  a  developmental  point  of  view 
and  represents  a  distinct  malformation.  The  laminae  close  normally 
at  the  beginning  of  the  fourth  month  of  fetal  life,  and  fusion  takes 
place  at  the  base  of  the  spinous  processes  from  above  downward. 
As  the  lumbar  vertebrae  are  the  last  to  unite,  spina  bifida  is  most 
common  in  the  lumbar  region.  A  true  spina  bifida  commonly 
appears  as  a  tumor  in  the  lower  part  of  the  spine  or  in  the  sacrum, 


74  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

and  is  covered  with  either  healthy  or  diseased  tissue,  which  is  usually 
very  thin  and  transparent.  At  times  the  tumor  is  solid,  containing 
only  fibrous  and  fatty  tissue,  with  no  connection  with  the  spinal 
cord  or  canal  other  than  a  dense  fibrous  pedicle  with  no  nerve  tissue 
or  filaments  included.  At  other  times  it  may  be  represented  simply 
by  a  defect  in  the  skin  covered  usually  by  a  tuft  of  coarse  hair;  in 
this  latter  case  it  is  called  spina  bifida  occulta.  The  condition  of 
pylo-ni do-sinus  must  of  course  be  thought  of  differentially,  but 
would  usually  be  readily  distinguished  from  spina  bifida. 

Plate  42  represents  the  photograph  of  a  case  of  spina  bifida 
occulta  occurring  in  a  girl  three  and  a  half  years  old.  The  muscles 
of  the  right  thigh  were  atrophied. 

Plate  43  shows  a  Roentgenograph  of  the  same  case.  The  ver- 
tebrae above  the  sacral  region  do  not  show  any  numerical  varia- 
tions, and  not  being  well  developed  are  not  easily  distinguishable. 
There  is  a  definite  change  not  only  in  structure  but  in  size  of  the 
third  lumbar  vertebra.  The  third  intervertebral  disc  is  narrowed. 
The  fourth  and  fifth  lumbar  vertebrae  are  larger  and  narrower  from 
side  to  side  with  very  small  and  irregularly  shaped  spinous  processes. 
There  is  a  partial  sacralization  of  the  transverse  processes  of  the  fifth 
lumbar  vertebra.  The  sacrum  presents  a  cleft  to  the  left  of  the 
median  line.  A  dislocation  of  the  right  femur  is  shown  to  be  present, 
and  is  probably  congenital  in  origin.  A  rudimentary  acetabulum 
and  a  delayed  development  of  the  right  upper  femoral  epiphysis  are 
shown. 

Plate  44  represents  the  lumbar  vertebrae,  pelvis,  and  thighs  of 
the  same  case.  The  spinous  processes  of  the  third  and  fourth  lumbar 
vertebrae  are  bifid.  The  child  was  operated  on,  and  the  plate  shows 
the  abnormal  conditions  five  months  later,  and  represents  an  appar- 
ently satisfactory  reduction  of  the  femur.  The  dislocation  of  the 
femur  was  not  recognized  chnically. 


DISEASES  OF  THE  NEW-BORN.  75 

RIBS 

A  precise  knowledge  of  an  anomalous  condition  of  the  ribs, 
such  as  fusion  of  the  ribs,  an  extra  rib,  or  any  malformation  of  the 
ribs,  is  often  of  great  value  when  the  physician  washes  to  determine 
the  best  point  of  entrance  when  performing  thoracentesis. 

Plate  45  illustrates  this  fact.  It  is  that  of  a  child  who  showed 
a  congenital  fusion  of  the  sixth,  seventh,  and  eighth  ribs  on  the  left 
side.  Especially  evident  are  the  greatly  deformed  fourth,  fifth, 
sixth,  and  seventh  dorsal  vertebrse,  and  a  decided  scoliosis  to  the 
right.  To  be  noted  also  in  the  lower  lumbar  region  was  a  marked 
spina  bifida  (not  shown  in  the  plate) .  If  in  a  case  of  this  kind  there 
happened  to  be  a  pleuritic  or  pericardial  effusion  the  information 
gained  from  the  Roentgenograph  would  be  of  infinite  aid  and  almost 
absolutely  necessary'  in  determining  the  position  of  the  heart  and 
at  what  point  the  needle  should  be  introduced. 

In  cases  of  torticollis  it  is  often  very  difficult  to  determine  the 
cause  of  the  condition  without  having  recourse  to  the  Roentgen 
method  of  examination.  This  is  especially  evident  where  the  clinical 
symptoms  arise  from  a  malformation  of  the  vertebrae  or  ribs.  Plate 
46  explains  the  cause  of  the  condition  where  the  clinical  picture 
was  that  of  torticollis  to  the  right  in  a  child  six  years  old  in  whom 
the  Roentgenograph  showed  that  there  was  a  congenital  cer\'ical 
rib  attached  to  the  seventh  cervical  vertebra  on  the  left  side,  while 
on  the  right  side  of  the  same  vertebra  there  was  none.  On  the  side 
of  the  malformation  the  child  will  be  seen  to  have  thirteen  ribs, 
instead  of  the  twelve  which  normally  appear  on  the  right  side. 

In  connection  with  the  ribs  and  spine  a  malformation  of  the 
scapula  is  found  at  times.  Although  this  condition  can  usually  be 
detected  by  the  usual  external  physical  examination,  yet  it  is  far 
more  satisfactorily  explained  by  means  of  the  Roentgen  method. 

Plate  47  shows  the  photograph  of  a  boy  six  years  old  with  an 


76  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

elevation  of  the  scapula  on  che  left  side.  He  also  shows  a  marked 
scoliosis  to  the  left. 

Plate  48  shows  a  Roentgenograph  of  the  same  deformity.  In 
this  picture  is  shown  the  scapula  in  the  region  of  the  muscles  of  the 
neck  on  the  right  side,  while  the  clavicle  on  the  opposite  side  is  in 
its  normal  position.    The  remainder  of  the  picture  is  normal. 

Plate  49  shows  the  same  condition  in  an  infant  six  montlis 
old.  In  this  case  the  elevation  of  the  scapula  reached  high  up  into 
the  neck.  There  is  also  a  left  dorsal  curve  of  the  spinal  column. 
The  first  dorsal  vertebra  also  shows  some  deformity.  Otherwise 
the  picture  is  normal  for  the  age. 

INTRA-THORACIC  AND  INTRA-ABDOMINAL  ANOMALIES 

Although  the  detection  of  the  various  transpositions  of  organs, 
as  the  heart  in  the  thorax  and  the  liver  in  the  abdomen,  is  compara- 
tively simple,  yet  there  are  cases  in  which  it  is  almost  impossible  to 
determine  whether  the  transposition  of  a  heart  is  due  to  a  congenital 
deformity  or  to  adhesions  holding  it  out  of  position.  In  such  cases 
as  these  we  have  to  depend  upon  the  transposition  of  other  organs, 
such  as  the  liver  or  spleen  or  stomach,  as  shown  by  the  ray.  Plate 
110,  Division  VI,  is  an  illustration  of  this  difficulty. 

ANOMALIES  OF  THE  EXTREMITIES 

In  connection  with  the  study  of  the  bones,  especially  of  the 
extremities,  it  is  well  to  understand  that  all  congenital  deformities 
in  connection  with  the  bones  show  their  changes  in  the  epiphyses. 
Among  the  anomaUes  of  the  new-born  the  malformations  of  the 
hands  and  feet  appear  to  be  the  most  common,  but  no  part  of  the 
osseous  system  is  exempt.  Until  the  Roentgen  ray  came  into  general 
use  these  conditions  could  only  be  studied  by  what  could  be  seen 
externally  or  at  the  post-mortem,  although  an  actual  and  precise 
knowledge  of  the  relation  of  the  bones  to  each  other  was  very  neces- 


DISEASES  OF  THE  NEW-BORN.  77 

sary  in  order  to  obtain  the  best  results  from  operative  treatment. 
Club-hand  and  club-foot  are  congenital  malformations  which  may  be 
due  to  an  undeveloped  condition  of  either  the  bones,  the  ligaments, 
or  the  muscles,  and  the  Roentgenograph  is  therefore  of  the  greatest 
importance  in  determining  which  condition  is  present  in  the  especial 
individual.  In  the  more  simple  forms  the  extremity  is  pulled  into 
position  by  the  action  of  contracted  muscles  or  tendons.  In  the 
more  severe  forms  the  bones  may  be  so  misshapen  that  the  separate 
segments  are  almost  unrecognizable,  and  therefore  a  picture  of  these 
segments  is  required  for  intelligent  operative  interference.  For 
practical  use  surgically  we  may  divide  the  malformations  of  the 
hands  and  feet  into  three  types : 

An  extra  fully  developed  separate  digit. 

A  fully  developed  hand  or  foot  with  one  or  more  digits  webbed, 

or  with  a  single  or  multiple  anomalous  condition  of  any  of 

the  carpal  or  tarsal  bones  or  the  phalanges,  metacarpal,  or 

metatarsal  bones. 
A  hand  or  foot  with  a  less  number  of  fingers  or  toes  than  normal 

and  with  an  imperfect  development  of  one  or  more  bones. 

Upper  Extremities. — As  illustrations  of  the  various  tj^pes  of 
deformities  just  spoken  of  are  the  following: 

Plate  50  (Fig.  1),  the  hand  of  a  child  two  months  old,  shows 
a  webbed  condition  of  the  second  and  third  phalanges.  A  number 
of  deficiencies  are  also  present  which  may  be  seen  in  the  illustration. 
It  is  to  be  especially  noted  in  this  plate  that  none  of  the  epiphyses 
of  even  the  metacarpal  bones  are  present.  Otherwise  the  bony 
structure  is  fairly  normal. 

Fig.  2  shows  the  left  hand  of  a  child  one  and  a  half  years  old. 
The  Roentgenograph  shows  an  extra  digit,  and  also  the  fusion  of 
the   fifth  and   extra  metacarpal   bones.     The  Roentgenograph   in 


78  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

this  case  was  of  course  of  the  utmost  aid  in  determining  what  the 
operative  treatment  should  be. 

Plate  51  shows  a  photograph  (Fig.  1)  of  a  boy  ten  years  old 
with  double  congenital  club-hands.  The  picture  also  shows  a  defi- 
ciency in  the  number  of  the  fingers,  the  thumb  being  absent  and  two 
of  the  fingers  of  the  left  hand  being  webbed.  The  Roentgenograph 
(Fig.  2)  of  this  case  shows  a  number  of  anomalous  conditions  which 
are  described  in  the  corresponding  legend.  Club-hand  is  often  accom- 
panied by  an  absence  of  the  radius,  and  this  condition  is  shown  in 
the  Roentgenograph.  It  is  to  be  noted  that  the  bones  in  this  case 
are  smaller  than  normal  and  show  a  deficiency  in  the  lime  salts. 
The  deformities  in  this  case  are  so  complex  that  it  is  evident  that  a 
Roentgenograph  was  necessary  if  any  radical  surgical  operation  was 
to  be  performed.  Also  to  be  noted  in  this  plate  is  the  absence  of 
the  epiphysis  of  the  lower  end  of  the  humerus,  the  slightly  developed 
epiphysis  of  the  lower  end  of  the  ulna  of  the  right  hand,  the  rudi- 
mentary metacarpal  bone  of  the  left  hand,  and  the  lack  of  develop- 
ment of  the  carpal  bones. 

Plate  52  shows  a  deformity  of  both  ulna  and  radius,  and  a 
bowing  of  the  ulna  seemingly  in  order  to  compensate  for  the  radius, 
which  is  considerably  shortened. 

Plate  53  shows  an  anomalous  condition  in  the  arm  of  a  boy 
ten  years  old.  The  abnormal  difference  in  size  in  the  bones,  and 
in  the  outline  and  dislocation  of  the  radius,  and  also  the  irregular 
deposit  of  bone  in  the  ulna  probably  arise  from  some  unknown  con- 
genital cause. 

Lower  Extremities. — Plate  54  shows  the  photograph  of  the  feet, 
only  two  toes  being  present,  of  a  boy  eight  years  old.  The  Roentgeno- 
graph shows  a  fusion  of  the  astragalus  and  the  os  calcis.  Accord- 
ing to  Dwight,  this  abnormal  condition  occurs  at  the  posterior  end 
of  the  sustentaculum,  and  may  be  attributed  to  the  fusion  of  the 


DISEASES  OF  THE  NEW-BORN.  79 

OS  sustentaculi  with  both  bones.  The  bones  may  be  firmly  ossified 
or  they  may  be  united  by  gristle,  the  apposed  surfaces  showing  the 
characteristic  irregular  finish.  Either  of  these  conditions  is  decidedly 
uncommon.  A  Roentgenograph  was  manifestly  ver>'  important  in 
this  case. 

Plate  55  shows  another  somewhat  similar  deformity  of  a  child's 
foot  in  which  only  one  toe  is  present. 

A  very  striking  instance  of  how  important  to  the  surgeon  may 
be  the  anomalous  conditions  connected  with  the  malformations  of 
the  foot  is  represented  in  Plate  56.  This  is  the  foot  of  a  child 
three  years  old.  It  shows  the  absence  of  the  tarsal  bones,  with  the 
exception  of  two  which  are  very  slightly  developed.  The  metatarsal 
bones  are  also  absent.  This  case  was  under  the  care  of  an  orthopaedic 
surgeon  for  some  time  and  was  considered  to  be  connected  with  the 
malformation  of  club-foot.  The  Roentgen  ray  showed  the  anomalous 
condition,  and  the  knowledge  received  from  it,  if  it  had  been  obtained 
earUer,  would  have  saved  the  patient  months  of  treatment.  Of 
course  to  understand  thoroughlj^  such  an  anomalous  condition  as 
this  it  is  necessar}^  to  compare  this  picture  with  that  of  the  normal 
average  development  at  three  years. 

Plate  57  shows  the  delayed  development  of  the  right  lower 
extremity  in  a  child  six  months  old.  There  is  an  entire  lack  of  devel- 
opment of  both  trochanters,  and  the  upper  epiphysis  of  the  right 
femur  is  markedly  smaller  than  the  left.  E\4dently  the  cartilage 
has  been  arrested  in  its  change  into  bone  at  an  early  period,  while 
on  the  opposite  side  this  process  has  continued  normally,  and  the 
resulting  shortening  of  the  leg  is  shown  by  the  ray.  Plate  58  shows 
the  lower  legs  and  feet  in  the  same  case.  On  comparison  with  the 
foot  of  a  child  of  the  same  age  it  shows  a  lack  of  development  of  the 
deformed  limb  and  of  the  tarsal  bones  of  the  foot,  the  undeveloped 
epiphysis  of  the  tibia,  and  the  general  irregular  distribution  of  the 
metatarsal  bones. 


80  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

ANOMALIES  OF  THE  PELVIS 

Congenital  dislocations  of  the  hip  are  the  most  frequent  of  and 
play  an  important  role  in  the  malformations  of  the  new-born.  They 
depend  upon  a  faulty  development  of  the  acetabulum  and  of  the 
head  of  the  femur.  Plates  59  and  60  show  instances  of  this  nature. 
These  Roentgenographs  are  of  especial  importance  in  that  they 
make  e\'ident  whether  the  dislocation  is  due  to  a  lack  of  development 
of  the  acetabulum,  to  an  absence  of  the  head  of  the  femur,  or  to 
some  other  anomalous  condition  which  it  would  be  impossible  other- 
wise to  recognize  during  life  or  without  operation.  With  the  aid 
of  the  Roentgenograph  the  operation  can  be  determined  with  more 
exactness  than  by  any  other  method. 

Plate  59  shows  the  dislocation  of  both  femora  in  a  child  twelve 
and  a  half  years  old. 

Plate  60  shows  a  congenital  dislocation  of  the  left  femur  in  a 
child  ten  j'^ears  old. 

Plate  61  represents  the  legs  of  a  child  where  there  was  a  con- 
genital paralysis  on  both  sides.  The  cause  was  not  determined,  but 
was  supposed  to  be  the  result  of  some  congenital  lesion  of  the  cord. 
As  shown  by  the  Roentgenograph  there  is  an  undeveloped  and 
atrophic  condition  of  the  acetabulum  and  femur.  The  atrophy  is 
not  in  quality  but  only  in  size. 

BACKWARD  MENTAL  DEVELOPMENT— MYXCEDEMA— CRETINISM 

Plate  62  shows  the  hand  of  a  case  of  hydrocephalus,  and 
delayed  development  of  the  carpal  bones  in  an  infant  twenty- 
three  months  old.  In  addition  to  the  delayed  development  of 
the  bones,  which  represent  chronologically  about  six  months  of 
age,  there  is  to  be  noted  an  anomalous  ossific  centre  at  the  proxi- 
mal end  of  the  second  metacarpal  bone,  which  may  be  possibly 
the  trapezoid,  trapezium,  or  an  anomalous  epiphysis. 


DISEASES  OF  THE  NEW-BORN.  81 

Plate  63  shows  the  hand  of  a  boy  four  years  and  nine  months 
old,  who  was  decidedly  backward  in  his  mental  development,  and 
whose  hand  shows  that  the  wrist  is  developed  about  as  much  as 
would  be  usually  found  between  the  second  and  third  year. 

Plate  64  shows  the  hand  of  a  girl  eight  years  old,  with  myx- 
oedema.  Nothing  especially  abnormal  is  noticed  in  the  bones,  ex- 
cepting that  the  wrist  presents  a  development  about  two  years 
behind  what  would  usually  be  normal  for  eight  years  in  a  girl. 

Plate  65  shows  the  delayed  development  of  the  carpal  bones 
in  the  hand  of  a  sporadic  case  of  cretinism  in  a  child  twenty- 
seven  months  old.  It  also  shows  the  ill-developed  bones  of  the 
leg,  and  the  narrow  zone  of  proliferation  which  is  supposed  to 
occur  in  cases  of  cretinism.  Fig  3  shows  this  narrow  zone  in  a 
section  of  the  femur  of  a  cretin.  This  specimen  is  in  the  Warren 
Museum  of  the  Harvard  Medical  School. 

CHONDRODYSTROPHIA  FOETALIS  (ACHONDROPLASIA) 

Although  various  names  have  been  used  to  represent  this  con- 
dition, investigators  at  present  as  a  rule  prefer  to  limit  the  term  to 
chondrodystrophia  fcetalis.  In  order  to  recognize  the  disease  from 
a  Roentgen-ray  point  of  view  the  gross  anatomy  and  coarse  histology' 
should  first  be  carefully  studied.  In  this  way  the  Roentgenograph 
can  differentiate  this  disease  of  the  new-born  from  such  changes  in 
the  bones  as  take  place  in  osteogenesis  imperfecta,  and  those  nutri- 
tive conditions  acquired  after  birth,  such  as  rhachitis  and  osteoma- 
lacia. The  word  achondroplasia  was  first  used  to  represent  this 
condition  by  Parrot  in  1878;  but  Kaufmann,  in  1892,  in  describing 
the  pathology  of  the  disease,  spoke  of  it  as  a  disturbance  of  the 
endochondral  ossification,  while  the  ossification  on  the  side  of  the 
periosteum  was  perfectly  normal.  Later  investigators  have  usually 
followed  Kaufmann  in  using  the  name  chondrodystrophia  fcetalis. 

6 


82  THE  ROENTGEN  RAY  IX  PEDIATRICS. 

It  is  a  disease  of  the  osseous  system  beginning  in  intra-uterine  life 
between  the  third  and  sixth  months  and  usually  ending  at  birth. 
Its  effects,  however,  persist  through  life.  Owing  to  similar  macro- 
scopic appearances  it  is  often  erroneously  classified  as  fetal  rhachitis, 
but  microscopically  it  presents  marked  differences.  The  cause  is 
not  known.  It  is  usually  accompanied  by  general  malnutrition, 
and  the  majority  of  the  cases  die  soon  after  birth,  but  the  less  severe 
cases  are  compatible  with  life.  The  characteristic  changes  in  the 
bone  result  in  shortened  and  deformed  extremities,  and  a  large  square 
head  and  flattened  nose,  but  the  trunk  usually  remains  normal. 
These  abnormalities  are  brought  about  by  a  disturbance  in  the 
normal  process  of  ossification  of  the  primary  cartilages.  The  flatten- 
ing of  the  bridge  of  the  nose  is  due  either  to  primary  tribasilar  synos- 
tosis or  a  failure  of  development  which  causes  the  base  of  the  skull 
to  be  shortened.  In  the  long  bones  a  cartilaginous  ossification  of  the 
epiphyses  results  in  an  arrest  of  development  and  a  corresponding 
shortening.  The  shafts  consist  chiefly  of  periosteal  bone,  while  the 
medullar^'  canal  is  sometimes  replaced  by  hard  bone.  The  ends 
of  the  bones  may  be  so  affected  by  the  overgrowth  of  periosteum 
as  to  produce  deformities  which  closely  resemble  those  of  rhachitis. 
Similarly  there  may  be  at  the  junction  of  the  ribs  and  cartilage  a 
flattening  of  the  sides  of  the  chest,  and  there  may  be  also  a  flatten- 
ing of  the  pelvis. 

Kaufmann  has  divided  chondrodystrophia  foetalis  into  three 
types:  (1)  chondrodystrophia  hypoplastica,  in  which  there  is  a 
failure  of  the  development  of  the  cartilage;  (2)  chondrodystrophia 
malacica,  in  which  there  is  an  abnormal  softening  of  the  cartilage; 
(3)  chondrodystrophia  hyperplastica,  in  which  there  is  excessive 
development  of  the  cartilage  in  all  directions.  Osteoporosis  and 
osteosclerosis  may  occur  as  complications.  A  tendency  to  deformity 
in  these  cases  may  be  increased  by  fractures.    Instead  of  the  enlarge- 


DISEASES  OF  THE  NEW-BORN.  83 

ment  of  the  ends  of  the  long  bones  due  to  excessive  enlargement  of 
the  epiphyseal  cartilage,  as  is  seen  in  rhachitis,  chondrodj^strophia 
shows  an  overgrowth  of  the  periosteum.    The  zone  of  proliferation 
while  it  is  widened  in  rhachitis  is  narrowed  in  chondrodystrophia, 
and  the  vascularization  in  the  latter  disease  is  marked.     There  is 
probably  no  direct  relation  between  chondrodystrophia  and  cretinism. 
The   differential    diagnosis   between   chondrodj-strophia,    rhachitis, 
osteomalacia,  and  other  diseases  by  means  of  the  Roentgen  ray  is 
given  on  page  107.    Since  the  introduction  of  the  Roentgen  method 
of  examination,  a  diagnosis  on  the  living  subject  of  the  various 
intra-uterine  conditions  connected  with  the  bones  and  with  their 
epiphyses  has  rapidly  advanced  in  precision.     While  in  the  past 
there  has  been  almost  inextricable  confusion  in  the  differentiation 
of  these  diseases,  we  can  now  make  a  diagnosis  with  a  fair  chance 
of  its  being  correct.     Especially  to  be  noted  is  the  recognition  as 
distinct   diseases  of   the  conditions  of   chondrodystrophia  fcetalis, 
osteogenesis    imperfecta,    cretinism,    and    possibly   fetal    rhachitis. 
Up  to  the  present  time,  however,  no  case  of  intra-uterine  rhachitis 
which  has  been  studied  by  modern  methods  of  examination  has  been 
published. 

Plate  66  shows  two  cases  of  chondrodystrophia  fcEtalis.  Fig.  1 
is  the  picture  of  a  girl  five  and  a  half  years  old,  showing  the  flattened 
nose,  comparatively  short  arms,  and  especially  short  legs  of  a  case  of 
chondrodystrophia  foetalis.  For  the  description  of  this  case,  see 
''Pediatrics,"  page  333,  fifth  edition. 

Fig.  2  is  the  picture  of  a  boy  thirteen  years  old,  showing  the 
flattened  nose,  the  short  legs,  and  the  noticeably  short  arms. 

Plate  67  shows  the  Roentgenograph  of  the  hand  of  the  same 
case.  Fig.  2,  in  comparison  with  the  normal  hand  (Plate  20)  of  a  boy 
nine  years  old.  A  number  of  changes  besides  the  broad  thickened 
bones  will  be  noticed. 


84  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Durante,  in  1902,  stated  that  "  the  cartilage  shows  more  vascu- 
larization than  normal.  It  is  separated  from  the  border  zone  by  a 
vascular  fibrous  band.  This  band  diminishes  in  breadth  inward 
and  towards  the  centre  of  the  epiphysis  and  is  often  represented 
only  by  an  interstitial  sclerosis  of  the  layer  of  the  cartilage  cells, 
which  are  disposed  parallel  to  the  line  of  ossification.  Below  this 
the  proliferation  and  arrangement  of  the  cartilage  cells  is  very 
defective.  The  cells,  well  separated  in  the  midst  of  an  interstitial 
substance  suggesting,  fibrous  tissue,  are,  as  a  rule,  not  disposed 
in  columns  even  partially.  There  often  is  no  trace  of  cartilage 
columns,  and  the  cells  lie  isolated  and  scattered  without  order, 
even  up  to  the  edge  of  the  line  of  ossification.  From  this  there 
results  the  formation  of  bony  lamellae,  small,  thin,  and  essentially 
irregular,  or  rather  a  series  of  points  of  calcified  nodules  irregularly 
disseminated  in  the  marrow  of  the  bone.  A  certain  number  of  pro- 
jections of  marrow  occupy  the  line  of  ossification  and  extend  toward 
this  fibrous  band.  Below  the  line  of  ossification  the  medulla  is  rep- 
resented by  a  very  close  dense  areolar  connective  tissue  with  fibres 
decidedly  coarser  than  normal.  In  short,  there  exists  an  intense 
sclerosis  with  disappearance,  or  at  least  absence,  of  normal  medullary 
cells." 

While  the  cartilaginous  ossification  is  insufficient  and  defective, 
the  periosteal  ossification  appears  active,  though  equally  pathologic 
under  certain  aspects.  On  a  transverse  section  of  the  diaphysis  of 
the  femur,  we  perceive  the  eccentric  position  of  the  medullary  canal, 
which  is  diminished  in  size.  We  nowhere  find  compact  bone.  These 
bony  partitions  may  run  parallel  to  the  surface  of  the  bone,  or  may 
be  perpendicular  to  it,  and  at  their  peripheral  ends  may  become 
lost  in  the  internal  fibre-bundles  (faisceaux)  of  the  periosteum. 
Where  the  periosteal  layer  begins  to  bend  inwards  and  to  calcify, 
there  is  a  transformation  of  the  periosteum  into  fibrocartilage  and 
then  into  ossification. 


DISEASES  OF  THE  NEW-BORN.  85 

Resume:  There  is  present  a  sclerosis  of  the  epiphyseal  cartilage 
while  in  preparation  for  multiplication.  A  lack  of  serial  arrangement 
of  the  cartilage,  and  a  deficiency  in  cartilaginous  ossification  succes- 
sively occurs,  while  processes  from  the  marrow  cross  the  line  of  ossifi- 
cation. Abundant  periosteal  ossification  is  produced  as  well  by 
means  of  osteoblasts  as  by  direct  calcification  of  the  fibrous  lamellae, 
but  only  eventuating  in  the  formation  of  a  spongj'  bone  with  thick 
resistant  lamellae.  There  is  sclerosis  of  the  bone-marrow.  This 
condition  is  entirely  distinct  from  that  known  as  osteogenesis  imper- 
fecta, in  which  the  periosteal  ossification  is  especially  defective. 
Mullen's  case  of  osteogenesis  imperfecta  (reported  in  1897)  showed 
that  the  endochondral  ossification  was  wholly  normal.  In  this  case 
no  real  periosteal  bone  formation  was  anywhere  established. 

The  shafts  of  the  bones  often  show  great  thickening  and  short- 
ening of  the  cortical  substance,  and  overgrowth  of  the  bony 
epiphysis  is  so  marked  that  it  often  appears  to  overlap  that  of  the 
epiphyseal  line. 

In  examining  the  living  conditions  in  these  cases,  first  the  peri- 
osteum shows  great  thickening;  second,  the  cortical  substance  is 
broader  and  thickened;  and  third,  the  medullary  canal  is  narrowed, 
sometimes  showing  its  cavity  to  be  replaced  by  hard  cortical  tissue. 
It  is  seen  that  the  arrest  of  development  and  consequent  shortening 
of  the  long  bones  is  due  to  the  cartilaginous  ossification  of  the  epiphy- 
ses, and  it  is  very  evident  that  these  abnormalities  are  brought 
about  by  the  disturbance  in  the  normal  process  of  ossification  in 
the  primary  cartilage.  Although  many  of  these  cases  are  born  in 
such  a  condition  that  they  do  not  live,  yet  the  milder  cases  recover, 
and  it  is  important  to  differentiate  by  means  of  the  Roentgen  ray 
this  class  of  cases  from  osteogenesis  imperfecta,  rhachitis,  and  various 
anomalies  such  as  the  shortening  shown  in  Plate  57. 

The  examination  by  the  Roentgen  method  of  cases  of  chondro- 


86  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

dystrophia  gives  results  as  characteristic  as  the  chnical  examination, 
though  varying  in  certain  details  of  the  bony  change  which  takes 
place.  A  description  of  the  Roentgen  pictures  of  these  cases  is  not 
definite  unless  we  divide  them  into  two  groups  and  consider  the  age 
of  the  individual. 

1.  The  cases  which  are  seen  up  to  pubescence. 

2.  The  cases  of  pre-pubescence  with  marked  deformities  of  the 
limbs,  and  in  which  a  secondary  lesion  of  the  joint  is  found. 

In  the  first  group  of  cases  the  typical  Roentgen  picture  of  a 
given  bone,  for  instance  the  tibia,  will  show  a  bone  that  is  shorter 
and  wider  than  the  bone  of  a  normal  child,  but  which  has  a  well- 
developed  ossific  centre  for  the  given  age  under  examination.  The 
picture  produced  by  the  bone  generally  compares  well  with  that  of 
a  normal  child.  Deformities  of  the  shaft,  with  the  exception  of 
bowing,  are  rare  in  this  group.  The  cortex  is  thicker,  particularly 
in  the  middle  of  the  shaft,  showing  considerable  deposit  of  bone, 
but  thinning  out  towards  the  diaphysis.  The  medulla,  though  small 
at  the  middle  of  the  shaft,  is  increased  proportionately  with  the 
thinning  of  the  cortex.  The  bone  structure  is  in  some  cases  prac- 
tically normal  as  compared  wnth  a  normal  child,  but  in  the  majority 
of  cases  is  coarser  and  sometimes  a  more  irregular  deposit  is  appar- 
ent, particularly  in  the  diaphyses.  The  most  characteristic  appear- 
ance of  the  long  bones  is  that  near  the  epiphyseal  ends  the  diaphyses 
are  spread  hke  a  cup  (Plate  67).  This  produces  a  T-shaped  outline 
without  anj'  disturbance  of  the  epiphyseal  line  or  zone  of  prolif- 
eration, though  it  may  be  uneven  and  show  more  or  less  fantastic 
shapes  as  compared  with  a  normal  individual.  They  are,  however, 
not  so  uneven  as  is  seen  in  diseases  of  nutrition,  such  as  rhachitis 
(see  Plate  88,  Division  IV),  where  there  is  a  definite  disturbance 
of  the  zone  of  proliferation,  but  where  the  ossific  centres  have  been 
well  formed  and  the  epiphyses  are  apparently  fitted  into  the  cup- 


DISEASES  OF  THE  NEW-BORN.  87 

like  diaphyseal  ends.  In  this  first  group  of  cases  there  is  nothing 
seen  in  the  Roentgen  plates  which  could  be  confused  with  rhachitis. 

The  second  group  of  cases  is  characterized  by  extremities  extra- 
ordinarily shortened  in  comparison  to  the  body.  The  upper  arms 
and  thighs  are  shortened  in  comparison  to  the  forearms  and  legs, 
but  are  distinguished  from  the  first  group  in  that  the  osseous  system 
shows  more  definite  pathologic  changes  in  the  joints,  such  as  scoliosis, 
kyphosis,  lordosis,  coxa  vara,  genu  valgum  or  varum,  with  ankylosis, 
partial  or  complete,  of  one  or  more  joints,  either  owing  to  a  mechani- 
cal distribution  or  to  a  pathologic  change.  In  the  Roentgen  exami- 
nation of  these  cases,  although  the  underlying  appearance  of  the 
bone  is  that  of  the  first  group,  we  have  added  a  more  definite  change 
of  the  articular  surfaces  of  the  joints  and  of  the  epiphyses  in  general. 

In  chondrodystropliia  there  is  a  rather  narrow  but  fairly  regular 
zone  of  proliferation,  the  shafts  are  short,  not  bent,  and  usually 
thick. 

OSTEOGENESIS  IMPERFECTA 
SYNONYMS:  FRAQILITAS  OSSIUM,  IDIOPATHIC  OSTEOPSATHYROSIS 

This  disease  is  characterized  by  brittleness  of  the  bones  and 
multiple  fractures.  It  has  been  shown  to  have  a  definite  pathology 
of  its  own.  As  at  birth  the  clinical  diagnosis  is  often  obscure  and 
unsatisfactory,  the  Roentgenograph  becomes  of  importance  in  differ- 
entiating between  this  condition  and  chondrodystrophia  foetalis, 
or  possibly  a  rare  case  of  infantile  osteomalacia.  In  considering 
this  class  of  congenital  diseases  we  must  remember  that  the  skeleton 
at  birth  is  still  in  its  formative  stage,  and  it  is  therefore  difficult  to 
distinguish  between  the  effects  of  disease  and  those  of  malformation. 
The  diagnosis  of  fetal  diseases  of  the  bone  has  been  greatly  confused, 
since  the  same  name  has  been  given  to  different  pathologic  and 
clinical  conditions,  and  different  names  to  the  same  disease.  As  is 
shown  by  Nichols,  however,  osteogenesis  imperfecta  has  a  distinct 


88  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

pathology  of  its  own  and  should  be  entered  under  its  own  heading. 
It  differs  from  osteomalacia,  chondrodystrophia,  and  rhachitis. 
I  have  been  unable  to  find  any  reliable  modern  report  of  a  histo- 
logic examination  made  of  a  case  of  osteomalacia  occurring  at 
birth,  although  of  course  it  is  possible  that  it  may  occur.  Osteo- 
genesis imperfecta  may  be  said  to  be  an  abnormal  intra-uterine 
condition  resulting  in  multiple  fractures  during  intra-uterine  life 
or  infancy.  Clinically  in  this  disease  the  infants  are  smaller  than 
normal  and  their  extremities  are  short  and  usually  curved.  The 
skin  is  thick  and  cedematous,  and  their  skulls  are  probably  imper- 
fectly ossified.  A  case  of  osteogenesis  imperfecta  was  referred  to 
me  by  Dr.  R.  W.  Lovett,  and  I  had  the  infant  under  my  care  until 
its  death  at  the  age  of  ten  months.  The  case  was  minutely  examined 
and  studied  post  mortem  by  Dr.  A.  G.  Nichols.  According  to  his 
examination  the  following  pathologic  conditions  were  found : 

"  The  new  trabeculse  are  formed  by  direct  metaplasia  of  persist- 
ing cartilage  cells  into  bone,  whereas  the  normal  development  of  the 
trabeculse  of  bone  is  formed  by  apposition  of  bone,  by  osteoblasts 
upon  a  persisting  cartilaginous  matrix.  In  this  condition  the  bone 
cells  are  large,  oval,  not  stellate,  and  show  no  tendency  to  form  con- 
necting canaliculse.  The  bones  in  this  condition  are  very  imperfectly 
formed,  and  would  suggest  a  general  diseased  condition,  the  character 
of  which  is  not  perfectly  clear.  The  fibrous  matrix  is  not  calcified 
as  in  normal  bone,  and  the  capsules  of  the  cartilage  cells  do  not 
rupture.  The  periosteum  does  not  form  normal  bone,  is  much  thicker 
than  normal,  and  is  incomplete.  The  Haversian  canals  are  supple- 
mented by  large  marrow  spaces  and  the  trabeculae  in  the  marrow 
canal  are  fewer.  Near  the  epiphyseal  lines  and  in  the  marrow  spaces 
of  the  cortex  the  marrow  consists  of  an  cedematous,  myxomatous 
connective  tissue.  The  whole  process  of  the  development  of  the 
bone  is  checked  and  is  of  an  abnormal  kind.    Metaplasia  of  cartilage 


DISEASES  OF  THE  NEW-BORN.  89 

is  very  much  greater  in  this  condition  than  normal,  while  apposition 
of  bone  is  much  less.  The  bones  show  lessened  density  and  appear 
thin  and  atrophied.  The  medullary  cavity  seems  to  be  increased  at 
the  expense  of  the  cartilage. 

"  The  epiphyseal  lines  are  sharp,  but  perhaps  less  regularly  so 
than  normal.  Fractures  are  numerous  and  appear  clearly  in  the 
Roentgenograph.    The  bones  show  increased  radiability. 

"  It  is  improbable  that  this  process  is  identical  with  the  process 
which  occurs  in  acquired  fragility  of  the  bones."  (For  a  more  com- 
plete histologic  report  of  this  condition,  see  British  Medical  Journal, 
October  4, 1906.) 

Plate  68  shows  the  forearm  of  a  girl  two  years  old.  Clini- 
cally there  were  no  deformities,  except  a  tendency  to  valgus  of 
the  left  foot.  The  shafts  of  the  long  bones,  especially  of  the  radius, 
were  thickened  and  heavy.  Numerous  irregularities  simulating 
a  callus  were  detected,  and  were  especially  well  marked  on  the 
left  humerus.  The  Roentgen  examination  showed  that  the  pha- 
langes of  the  fingers  were  regular  in  shape,  excepting  that  the 
proximal  portions  were  toothed  and  cup-shaped.  There  was  very 
little  cortical  bone  present,  and  the  bony  structure  was  coarse  \vath 
very  little  evidence  of  the  bone.  The  carpal  bones  were  delayed  in 
development.  The  radius  showed  e\'idence  of  at  least  two  fractures, 
and  the  ulna  of  one  or  more. 

The  lateral  view  of  the  leg,  Plate  69,  of  this  same  subject, 
shows  a  fracture  of  the  femur  without  any  e\'idence  of  cell  formation. 
The  outUne  of  the  bone  was  regular,  excepting  for  the  fracture. 
There  was  very  little  cortex.  The  medulla  was  increased  propor- 
tionately and  showed  marked  increase  of  radiability.  There  were 
coarse  trabeculae  in  the  structure  of  the  bone.  The  epiphyses  were 
poorly  defined  and  there  was  a  marked  increase  in  the  zone  of  pro- 
liferation of  all  the  bones.  A  fracture  was  also  apparent  in  the 
fibula. 


90  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Plate  70  shows  the  leg  of  a  girl  twenty-five  months  old.  There 
was  no  history  of  previous  multiple  fractures  in  the  family.  The 
legs  and  arms  of  the  child  seemed  very  weak  at  birth  and  they 
seemed  to  be  ver^'  sensitive  to  touch.  The  right  arm  just  below  the 
elbow  showed  on  palpation  displacement,  but  the  motion  of  the 
elbow  was  not  impaired.  Nothing  abnormal  was  discovered  about 
the  joints.  The  Roentgenograph  showed  an  unreduced  fracture  of 
the  lower  end  of  the  humerus,  and  three  fractures  of  the  left  arm, 
also  a  fracture  of  both  femurs.  The  lateral  view  of  the  leg  showed 
a  marked  overgrowth  of  periosteum,  with  evidence  of  fracture  in 
the  middle  of  the  shaft.  No  formation  of  callus  was  present.  The 
cortex  was  ill  defined  and  in  places  absent.  The  epiphyses  were 
fairly  regular,  but  there  was  considerable  disturbance  of  the  diaphy- 
seal portion  of  the  bones  which  were  toothed  and  cup-shaped.  A 
fracture  of  the  tibia  and  of  the  fibula  was  seen  to  be  present. 

FETAL  RHACHITIS 

Although  it  is  possible  that  rhachitis  may  be  of  fetal  origin, 
I  have  been  unable  to  find  satisfactory  proof  of  this  in  any  reported 
case  where  modern  methods  of  examination  have  been  employed, 
so  that  the  existence  of  intra-uterine  rhachitis  is  still  sub  judice. 

OBSTETRICAL  PARALYSIS 

The  most  common  form  of  paralysis  of  the  arm  occurring  at 
birth  is  that  of  the  upper  arm,  although  that  of  the  lower  arm  type 
occurs  at  times,  and  both  the  upper  and  lower  arm  type  may  be 
present  together.  A  knowledge  of  the  anatomical  conditions,  especi- 
ally of  the  upper  arm  type,  which  represents  these  forms  of  paralysis, 
is  important  in  connection  with  the  differential  diagnosis  from 
various  other  forms  of  paralysis  or  pseudoparalysis,  especially 
poliomyelitis  anterior.  This  is  especially  true  in  cases  of  obstetrical 
paralysis  where  this  condition  first  comes  under  the  physician's 


DISEASES  OF  THE  NEW-BORN.  91 

observation  in  older  children,  especially  where  the  whole  arm  is 
involved.  There  is  no  need  of  entering  into  the  question  of  etiol- 
ogy,  as  this  question  has  been  fully  discussed  by  a  number  of 
writers,  as  by  Thomas  on  the  lower  arm  type,  Boston  Medical  and 
Surgical  Journal,  October  19,  1905,  by  Stransky,  Centralblatt  s.  d. 
Grenzgeberte  d.  Med.  u.  Chi.,  1902,  and  by  Bullard,  Arner.  Journal 
Medical  Sciences,  July,  1907,  the  latter  paying  especial  attention  to 
the  upper  arm  type.  It  is  now  conceded  pretty  well  that  the  upper 
arm  type  at  least  is  produced  by  injurj^  due  to  stretching  of  the 
fifth  and  sixth  cervical  nerves  in  the  neck,  which  may  be  more  or 
less  ravelled  out  or  torn  asunder.  The  external  points  for  diagnosis, 
both  by  manual  examination  and  electrical  reaction,  hold  their 
own  place  in  importance.  In  some  cases  when  the  recognition  of 
the  condition  is  uncertain,  the  Roentgen  method  is  especially  useful 
for  completing  the  examination  and  determining  the  lesions  which 
are  characteristic  of  obstetrical  paralysis  pure  and  simple  without 
other  injuries.  There  may,  however,  be  a  number  of  other  anatomic 
conditions,  resulting  from  fractures  of  the  cla\acle  and  arm  and  dis- 
location of  the  shoulders,  which  may  so  complicate  and  obscure  the 
original  injur}'  of  the  cervical  nerves  that  a  precise  and  definite 
diagnosis  cannot  be  made  without  the  aid  of  the  Roentgen  method. 
It  is  therefore  necessary'  that  we  should  be  familiar  not  only  with 
the  normal  anatomic  development  of  the  shoulder,  elbow,  and  wrist 
at  different  stages  of  growth,  but  also  should  recognize  the  deformi- 
ties of  these  parts  which  are  dependent  on  the  obstetrical  paralysis 
itself. 

The  following  Roentgenographic  plates  illustrate  cases  of 
obstetrical  paralysis  of  the  upper  arm  type.  If  the  injurj'  has  existed 
for  some  time  after  birth  we  find  in  these  cases  evidence  of  atrophy 
or  non-development  of  the  bones,  in  addition  to  the  muscular  atrophy. 

Plate  71  shows  a  case  of  obstetrical  paralysis  in  a  boy  eight 


92  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

years  old.  Within  twenty-four  hours  after  birth,  paralysis  of  the 
left  upper  arm  was  noticed.  When  the  child  was  three  years  old 
the  parah'sis  of  the  deltoid  was  still  marked  and  some  atrophy 
of  the  left  shoulder.  At  present  he  can  elevate  his  arm  only  to  the 
level  of  the  shoulder  and  cannot  supernate  the  upper  arm  beyond 
the  median  line.  External  rotation  was  also  found  to  be  impaired. 
There  was  also  marked  shortening  of  the  left  arm,  with  atrophy  of 
both  the  upper  and  lower  arm  and  of  the  scapula.  A  Roentgeno- 
graph of  this  case  showed  a  rudimentary  development  of  the  glenoid 
cavity  and  of  the  head  of  the  humerus.  Ossification  of  the  upper 
epiphysis  of  the  humerus  and  of  the  epiphysis  for  its  greater  tuber- 
osity was  found  to  be  delayed.  The  scapula  was  smaller  than  on 
the  other  side.  The  superior  angle  of  the  scapula  was  elevated. 
The  acromial  process  was  shorter  and  narrower  than  that  on  the 
opposite  side  and  was  delayed  in  its  development.  There  was  no 
apparent  atrophy  of  the  shaft  of  the  humerus. 

Plate  72  shows  a  boy  six  years  old.  An  hour  after  birth  it 
was  noticed  that  neither  of  the  arms  could  be  moved.  When  he  was 
three  years  old  he  could  use  the  left  upper  extremity  from  the  shoul- 
der. He  could  flex  his  forearm,  but  could  not  completely  extend  it. 
He  could  not  pronate  or  supernate,  and  could  raise  his  arms  only 
about  the  level  of  the  mammae.  Seven  months  later  the  left  shoul- 
der was  found  to  be  higher  than  the  right,  the  head  of  the  humerus 
being  pushed  forward  to  the  left.  The  scapulae  were  of  equal  size, 
measuring  9  cm.  in  length.  The  atrophy  of  the  arm  and  forearm 
was  noticeable.  There  was  a  primary  rotation  of  the  arm  at  the 
shoulder,  and  the  shoulder  was  elevated.  The  movements  were 
for  the  most  part  free,  although  there  were  adhesions  between  the 
shoulder  and  the  scapula.  The  Roentgenograph  shows  the  left 
shoulder  to  be  lower  than  the  right,  and  there  is  considerable  atrophy 
in  size  of  the  shaft  of  the  humerus.    The  scapula  was  a  little  smaller 


DISEASES  OF  THE  NEW-BORN.  93 

on  one  side  than  on  the  other,  but  otherwise  seemed  to  be  normal. 
There  was  some  delayed  development  of  the  epiphysis  of  the 
humerus. 

Plate  73  shows  the  condition  of  obstetrical  paralysis  in  a  girl 
who  on  the  third  or  fourth  day  after  birth  was  noticed  to  be  unable 
to  move  her  right  arm.  She  could  move  her  fingers.  The  arm 
could  not  be  moved  at  all,  and  practically  there  was  no  voluntary 
movement  of  the  entire  arm  except  in  the  fingers.  Posterior  motion 
of  the  shoulder  was  painful  and  there  was  a  distinct  click  of  the 
cla\'icular  humeral  joint,  but  no  definite  crepitus.  A  Roentgeno- 
graph taken  four  months  later  showed  a  rudimentary  development 
of  the  glenoid  cavity,  delayed  development  of  the  epiphyses,  and 
the  scapula  to  be  verj-  much  smaller  than  normal,  with  a  prominent 
superior  angle  and  a  rather  large  acromial  process. 


PLATE  41. 
HEAD  AND  NECK. 

Boy,  age  6  years.    (Life  size.) 

A.  Orbit. 

B.  Sphenoidal  sinus. 

C.  Artifact. 

D.  Antrum. 

E.  First  temporary  molar. 

F.  Second  temporary  molar. 

G.  First  bicuspid. 

H.  First  upper  permanent  molar. 

/.  Second  lower  permanent  molar. 

J.  First  lower  permanent  molar. 

R.  Points  to  an  anomalous  condition  of  the  upper  cervical 
vertebrae. 


Plate  41 


PI.ATK  42. 

SI'IXA  HIIIDA  OCCn.TA. 

Girl,  age  3i  year^.    (Same  subject  as  Plates  43  and  44.) 

The  arrow  point.s  to  hair  and  .'^kin  which  cover  the  defect  in 
the  vertebra-. 

Congenital  di.slocatiou  of  risiht  hip. 


Platk  42 


PLAT1-.  43. 

PPIXA  BIFIDA  OCTTLTA. 

Girl,  age  3J  years.    (Same  subject  as  Plates  42  and  44.) 

A.  The  narrowed  third  lumbar  vertebra. 

B.  The  narrowed  third  intci'vertebral  disk. 

C.  Sacralization  of  the  left  fifth  lumbar  vertebra. 

D.  Just  to  the  risiht  and  below  the  point   of  the  arrow  i.-; 

fissure  of  the  first  bodj'  of  the  sacrum. 


Plate  43 


PLATE  44. 

SPIN' A  BIFIDA  OCCULTA. 

Girl,  age  3i  years.     (Same  Mibject  as  Plates  42  ami  4^.) 

The  arrow  points  to  thp  right  hip  after  reduetion. 

The  deformities  of  tlio  vertebric  and  sacrum  are  the  same 
as  in  Phite  42. 

Xote  the  retardcil  development  of  the  upper  epi]5hysis  of 
the  right  femur  in  comparison  with  that  of  the  left. 


Pl^ATK  44 


PLATE  45. 
FUSION-  OF  RIBS.    MARKED  SCOLIOSIS  OF  COXGENITAI-  ORK'.IX. 

Child,  age  about  4  years.     (Ueiluced  27%.) 

-4.   Hyoid  bone. 

B.  Wedged  dor-sal  vertebrae. 

C.  Fusion  of  ribs. 


Pr^ATE  45 


PLATE  46. 
COXGEN'ITAI.  TORTICOLLIS. 

Boy.  age  (.  years.     (Reduced  385%  ) 

.4.  Extra  rib. 
B.  Y'wA  rib. 


Pl.ATK   46 


m 


''a. -■■•  - 


PLATE  47. 

CONGENITAL  ELEVATION  OF  SCAPULA  ON  LEFT  SIDE. 

Boy.  age  G  years. 

.4.  Elevated  scapula. 
B.  Scoliosis. 


Platk  47 


PLATK  4S. 

COXGEXITAL  ELEVATION'  OF  HKilir  S(AI>ULA. 

Boy,  age  fi  year>.     (Reduced  39%.) 

The  luiiiw  jKiints  towards  the  superior  aiifjlc  of  the  scapula. 


PI.ATE  48 


;=4 


iT^ 


'i 


PLATE  49. 
CONGEXITAL  ELEVATION  OF  THE  RIGHT  SCAPULA. 

liifaDt,  age  G  month?;.     (Reduced  1G%,) 

A.  Scapula. 


Tlatk  49 


I 


j»^" 


PLATE  50. 

(Life  size.) 

Fk;.  1.  Infant,  Age  2  Months.     The  Arrow  Points  to  the 
Webbed  Fingers. 

Fill.  2.   Infant,  Age  IV  Years.     F.xtra  Digit. 

A.  Extra  digit. 

B.  Extra  inotacaipal  lioiic;   fusion  wilii  llic  lil'lli  iiieta- 

car])al  hone. 


FIG.  1. 


PliATE  50 


.«<2S 


FIG.  2. 


^^ 


% 


V 


w 


Pl.ATK  .-)1. 
COXGEXITAI.  DKFoinilTV  OF  HANDS  AM)  ARMS. 

Boy,  age  10  years. 

Fh;.  1.  PiioToc.RAi'n  OF  the  Arms  of  a  Rov  10  Yeahs  Old. 

Fic;.  2.  Shows  the  .Vhsexce  of  the  Radius  on  the  P»iciht 
Side,  .\xd  the  Ikregilar  Develop.mext  of  the 
Lower  Exd  of  the  Right  Humerus. 

Xoriual  (k'vclopmcnt  of  tlic  (i])]K'r  end  of  llio  rijrlit  ulna. 

Two  small  ill-(U'vclo]jed  carpal  bones  arc  soen  and  a  very 
slightly  developed  e])iphysis  of  the-  ulna. 

Tlie  left  arm  shows  an  ill-developed  lower  end  of  tlu-  humerus 
with  an  irieiiular  and  abnormal  lower  epiphysis.  Xeithcr  radius 
nor  ulna  is  seen  in  this  arm.  The  carpal  bones  are  considerably 
more  developed  than  in  the  riijht  wrist;  there  is  an  extremely 
irregular  development  of  the  first  finger.     The  thumb  is  absent. 


FIG.  1. 


PiiATi:  51 


FIG.    2. 


,-«•  f 


PLATE  52. 
MALFORMATION  OF  THE  RADIUS  AXIl  11. XA. 

Infanr,  af;e  S  iiu)nt)is, 

A.  Marks  the  fusion  of  tlu-  head  of  the  radius  with  the  upper 

end  of  the  vilna. 

B.  Capitellum. 


Pl^TE  52 


Mi^ 


S^Si      E'5'. 


PLATE  53. 
CONGENITAL  DISLOCATION  OF  THE  RADIUS  AND  ILNA. 

Boy,  age  10  years.    (Reduced  25%.) 

^4.  Marks  a  bone  cyst  at  the  lower  end  of  the  ulna. 

B.  Marks  the  ilislocatioii  of  the  ujiper  end  of  the  radius. 

C.  CapitcUum. 

D.  Upper  epiphysis  of  the  radius. 

E.  External  condvle  of  the  lower  end  of  the  humerus. 


Plate  53 


TLATK  .-,4. 
CONGEXITAI,  DEFORMITY  OF  FOOT. 

Boy,  a^e  8  years. 

Fig.  1.   PHoroiui.vrn  Showi.xg  oni.y  Two  Toes. 

Fig.  2.   RoENTGENocniAPii  of  the  Same  Foot. 

.1.   Marks  till'  fusion  of  the  os   calci.i  with  what  was 

probiil)ly  tlie  astragalus. 
B.   Points  to  the  first  metatarsal  bone. 
('.   Points  to  the  seeond  metatarsal  hone 

D.  Points  to  outline  of  the  tissues  of  the  heel. 

E.  Points  to  the  tendo  .\chillis. 


FIG.  1. 


PliATE   54 


FIG.    2. 


« E 


PLATE  55. 

ROEXTGEXOGRAPH  OF  A  COXGEXITAL  DEFORMITY 
OF  THE  FOOT. 

(Life  size.) 

SI10W.S  one  toe  und  a  rudimeiitarv  set'oiul  toe. 


Plate  55 


\ 


PLATE  oG. 
UNDEVELOPED  FOOT. 

Cliild,  age  3  years.     (Life  size.) 

Congenital  ahsmcc  of  the  tarsul  lionos,  only  two  small 
ossific  centres  appearing,  probably  the  on  ealcis  and  the  astrag- 
alus. 

The  lower  epiphyses  of  the  tibia  and  fibida  are  present. 

Note  the  meshes  in  the  fat  tissue  of  the  heel  in  contrast 
with  the  cartilage  in  the  tarsal  region,  the  muscles  and  the 
tendo  Achillis. 


PliATK  56 


^ 


PLATE  57. 
COXGEMTAL  DELAYED  DEVELOPMEXT  OK  THE  RICIIT  LEG. 

Infant,  ape  tj  montlis.     (Patient  (»f  Dr.  Jolin  I.ovett  Morse.)     (Same  subject  a-*  Plate  58.) 

(Reduced  17%.) 

Tlic  arrow  points  towarils  the  small,  ill-(l('Vfl()])C'd  uppci- 
epiphysis  of  the  right  femur. 

Note  the  shorteneil  femur  and  the  small  size  of  the  femur, 
tibia,  and  fibula  in  comparison  with  the  left  leg. 


PliATK   oT 


PLATE  5S. 

Same  -subject  as  Plate  57.     (Reduced  29^";;  ) 


Shows  the  lower  part  of  the  tibia  and  fibula  and  the  foot. 
The  arrow  points  towards  the  very  small  and  i)oorly  devel- 
oped ossific  centre  of  the  lower  epiphysis  of  the  tibia. 


Plate  58 


A. 
B. 
C. 

side. 


PI.ATK  :.!). 
norBi.i:  foxcExiTAL  dislocatiox  ok  Tin:  iiir. 

(;irl.  age  IJJ  yua  s.     (Re.lun-.l  S-I^c-) 

ilarks  tlic  \v:ui(l('rin<i'  aoctabuluni  on  the  Icfl  side 
Marks  the  ii]i])ci-  cpiiiliysis  of  tlic  left  fciiuir. 
iMai'ks  tlic  true  or  normal  position  of  the  acctabiiluin. 
The  same  dcformitv  of  the  acotabulinn  i.s  soon  on  the 


iht 


PliATE   59 


PLATE  60. 
CONGEMTAL  DISLOCATION  OF  THE  LEFT  FEMUR. 

Hoy,  a^e  10  years.     (Reduccti  37*^.) 

.1.  Shows  the  ludiiuentarv  ischuitic  portion  of  the  acotahuluni. 
B.   Marks  the  ihac  portion  of  the  afetabuluin. 

Note  the  rudimentary  condition  of  the  epi])hysis,  and  of 
the  neck  and  shaft  of  the  left  femur. 

Note  also  the  atrophy  of  size  of  tiic  left  femur  in  comparison 
with  the  right  femur. 


Pirate  «>0 


IM.ATI-:  111. 

ATROPHY  IX  SIZE  OF  BOTH  FEMORA  DUE  TO  PAH  \I.VSI8 
OF  THE  LEGS. 

Infant,  a^e  abont  2  years.     (Reduced  31%.) 

A.   Marks  till-  ill-ilcfincil  acctaliiiluin. 

The  cause  of  this  eoiuHtioii  was  unknuwii. 


Platk  G1 


^ 


I 


L^sv- 


PLATE  62. 

AN  A.NOMAI.ors  KriPIIYSIS  OF  THE  SKCOXD  MKTACAKI'AL  BOXK 
AT  ITS  PROXIMAL  KXTUKMITY.  OR   IT  MAY   UK  THE 
TRAPEZOID  OR  TRAPEZIUM. 

(Life  size.) 


Platk  <>2 


4 

i 


f 


Pi.ATK  a:?. 

RETARDED  DEVELOI'MENT  OF  THE  BUAIX  AND  IIAXD. 

Boy,  age  4  years  and  9  months.     (Life  size.  ■ 

The  hiuul  shows  a  development  of  between  two  ami  three 
years. 


Plate  63 


PLATE  f)4. 

M'i'XCEDEMA— RETARDED  DEVELOPMEXT. 

Girl,  age  8  years.    (Life  size.) 

The  cuipal  bonos  show  a  development  of  six  year.s.     Other- 
wise noniuil. 


Plate  G4 


t 


PI.ATl':  65. 
IRREGULAR  l>i:VEL(  )1>MEXT. 

Girl,  age  27  months.     (Samn  wubjecl  as  Plates  1  l."i,   1  1(1.  anil  117. 

I'ld.  1.  Till',  Development  Compahes  tk  thai'  or  ihk  L.vrjKK 

I'.VHT  OF  THE    FlIiST   Ye.\K. 

Fid.  2.  Shows  Sm-\i.i,  lioNEs  in  Comparison  with  what  their 

DliVELOl'.MENT  SHOUI.I)   RE  AT  27  MoNTHS. 

The  itrniw  pdint.^i  to  tlic  ntirnnv  /.(inc  of  piolifcraliiin. 

Fig.  '.].  Section  of  Cketix   Hone. 

The  i-ul  sliows  a  section  from  tlic  hone  of  a  cictin.  The 
narrow  zone  of  proliferation  exemplifies  well  what  is  said  in  the 
text. 


Pt^atk  ()o 


FIG.  1. 


# 


FIG.   2. 


FIG.  3. 


Z.P 


PLATE  66. 
CIIUXDKODY.STROPHIA  FfETALIS. 

Fig.  1.  A  Giri.  o]  Ye.\ks  Old. 
Fig.  2.  A  Boy  13  Ykars  Old. 


FIG.  1 


rLATi:  (17. 
KKTAKDKI)  DKAKI.OPMK.NT  OF  THE  I'lSIl'ORM   HOXE. ' 

tianie  subject  as  Plate  (it).  Fig.  2.     (Life  size.) 

Mnrki'il  .shortening  anil  liroadcning  of  the  niotacarpal  bones 
ami  the  plialaug(_'.s.     Slight  irregularity  of  structure. 


Plate  67 


PLATK  ()S. 
OSTEOGENKSIS  IMPERFECTA. 

Girl,  age  2  years.     (Life  size.) 

.1.    I'lartuiT  about  the  niiddlo  of  the  radius. 
H.    I'racturc  of  the  upi)er  third  of  the  radius. 

C.  Thickening  of  periosteum  and  old  frai-ture  ;d)out  the  lower 

third  of  the  ulna. 

D.  Marked  fracture  about  the  ujjper  thinl  of  vdna. 

Note  the  slight  development  of  the  cortex  and  the  compara- 
tive increase  in  the  size  of  the  medullary  cavity.  Also  the  frreat 
irregularitv  of  the  outlines  of  the  bones. 


Plate  «8 


PLATE  ()9. 

OSTEOGEXESIS  IMPERFECTA. 

Same  :jubject  as  Plate  6S.    (RediicfU  7' Co-) 

^4.   Murks  fracturo  of  tho  upper  third  of  femur. 
B.  Marks  fracture  of  the  lower  thin!  of  fihula. 


Pl^TE  69 


PI.ATi;  70. 

OSTEOG  KXESLS   IM  PERFECTA. 

Girl,  age  23  monthji.    (Reduced  G%.) 

A.  Marks  a  fracture  of  the  upper  third  of  the  femur. 

B.  Marks  a  fracture  at  about  the  middle  of  the  fibula. 

Note  the  great  irregularity  of  outline  and  the  almost  com- 
plete ab.sence  of  the  cortex  of  the  femur,  tibia,  and  fibula,  also 
the  niarkeil  proliferation  of  the  tissues  and  the  periosteum. 


Platk  70 


Icfe 


-41 


PLATK  71. 
OBSTETRICAI>  PARALYSIS  OF  THE  LEFT  ARM. 

(Reduced  59%. i 

The  .shaft   of  the  humerus  shows  sUfi'it   atrophy  iu  .si/.e  in 
comparison  with  that  of  the  right  arm. 

.1.   The  unilcveloped  glenoid  eavity  on  the  left  side. 
B.  'Vhr  niai'keilly  elevated  sca])ula   with  its  irregular  angle  on 
tin-  left  side. 

A.  The  coracoid  process  of  the  scapula  on  the  i-ight  side. 

B.  The  acromial  process  on  the  right  side. 


PliATK  71 


Pl.ATi:  72. 
OBSTETRICAL  PAIiALYSlS  OF  THE  LEFT  ARM. 

lioy,  age  ()  years,     (lleduccd  5.1%.' 

Mark  the  atrophy  in  size  of  the  left  arm  and  shoulder  in 
funipari.'joii  with  that  of  the  right. 


Plate  72 


PLATI-:  7:5. 
OBSTETRICAL  PARALYSIS  OF  TIIK  RKiHT  SHOULDER. 

Girl,  ase  4  months.       (Uc.lucfcl  •29%.) 

A.  Marks  the  rvuliniontarv  "lenoid  cavity. 

B.  Marks  tlu-  acromial  process. 


Pj^ate  73 


^ 


Division  IV 

DISEASES  OF  NUTRITION 

In  contradistinction  from  those  diseases  which  have  a  distinct 
etiologA'  and  which  can  be  classified  according  to  their  etiological 
factors,,  is  a  class  in  which  abnormal  conditions  of  all  the  tissues  of 
the  body  arise  seemingly  from  lack  of  proper  hygienic  surround- 
ings and  from  poor  food.  This  group  comprises  osteomalacia,  infan- 
tile atrophy,  scorbutus,  and  rhachitis.  These  diseases  so  essentially 
belong  to  the  early  periods  of  life  and  are  so  obscure  in  their  etiologj^ 
while  presenting  each  in  its  own  peculiar  manifestations  a  clear 
picture  of  a  \dce  of  nutrition,  that  for  the  present  we  must  classify 
them  by  themselves  as  diseases  of  nutrition.  The  recognition  of 
the  early  lesions  of  these  diseases  is  important,  as  it  is  in  the  very 
beginning  that  the  later  and  more  serious  manifestations  may  be 
obviated.  Although  they  may  be  amenable  to  treatment,  yet  they 
render  the  indi\idual  infant  more  vnalnerable  to  disease  as  it  grows 
older,  and  leave  its  susceptible  tissues  in  such  a  condition  that 
when  it  is  exposed  to  specific  infections  these  infections  are  more 
dangerous  to  Ufe  on  account  of  the  lessened  resistance  of  the  tissues. 
The  Roentgen  method  of  examination  is  especially  valuable  in  this 
class  of  cases,  since  by  it  alone  the  earliest  abnormal  changes  which 
correspond  to  the  special  condition  can  be  recognized  and  its  treat- 
ment begun  before  more  pronounced  symptoms  and  graver  lesions 
lead  us  to  suspect  that  it  is  present.  It  is  in  this  class  of  diseases, 
as  well  as  in  that  which  is  represented  by  such  infectious  processes 
of  the  bones  as  osteomj'elitis  and  tuberculosis,  that  it  is  especially 
necessary  to  first  carefully  study  the  pathologic  lesions  as  shown 
by  post-mortem  examinations  before  attempting  to  diagnosticate 
them  by  means  of  the  Roentgen  method.    These  examinations  and 

95 


96  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

studies  of  dead  histologic  conditions  are  often  invalidated  because 
the  various  dead  lesions  are  terminal  processes  and  thus  do  not  show 
the  characteristic  lesions  which  during  life  represent  the  actual 
patholog}^  of  the  especial  disease.  This,  however,  is  in  so  many  cases 
only  a  presumable  difficulty  that  there  is  no  question  but  that 
if  we  recognize  this  pathologic  fact  we  can  recognize  sufficiently 
in  the  Roentgen  picture  the  typical  gross  lesions  which  will  enable 
us  to  diagnosticate  all  the  diseases  just  mentioned  during  Ufe.  That 
the  Roentgen  method  of  examination  can  accomplish  this  has  been 
clearly  proved,  so  that  to-day  we  are  in  a  position  where  an  early 
diagnosis  is  almost  always  possible  and  where  appropriate  treat- 
ment can  be  begun  at  once.  This  group  of  diseases  is  assuming  a 
more  and  more  important  position  among  the  morbid  conditions 
belonging  to  the  early  years  of  life.  It  is  becoming  evident  that 
it  is  more  far  reaching  in  its  effects  and  influences  to  a  much  greater 
degree  all  the  diseases  of  early  life  than  in  former  years  was  thought 
to  be  possible.  The  prognosis  in  those  diseases  which  have  a  defi- 
nitely determined  etiology  is  markedlj^  graver  where  such  diseases 
occur  in  an  infant  who  is  suffering  from  one  of  the  general  dis- 
turbances of  nutrition.  In  this  respect  especially  both  rhachitis 
and  infantile  atrophy  have  come  to  play  a  great  and  important 
role  in  our  study  of  infantile  diseases  in  general  and  in  their  thera- 
peutics. 

OSTEOMALACIA 

Osteomalacia  is  a  disease  which  occasionally  occurs  in  chil- 
dren, but  not  so  frequently  as  in  adults.  It  causes  softening  of 
the  bone  and  in  this  respect  is  somewhat  similar  to  rhachitis. 
According  to  Ziegler,  there  is  an  absorption  of  lime  salts,  beginning 
first  at  the  medullary  ca\'ity  and  proceeding  outward.  The  epiphyses 
are  not  notably  affected  by  the  continuance  of  the  absorptive  process, 
but  the  cortical  bone  becomes  spongy  and  decalcified,  and  in  the 


DISEASES  OF  NUTRITION.  97 

severest  cases  there  may  remain  little  but  marrow  and  periosteum. 
The  opinion  is  generally  held  that  in  osteomalacia  the  layer  of  osteoid 
tissue  results  from  decalcification,  while  in  rhachitis  a  similar  layer 
represents  a  new  growth  deficient  in  lime  salts.  According  to  Buck 
and  Bryant  osteomalacia  pathologically  consists  principally  in  decal- 
cification of  the  old  bone  with  a  simultaneous  formation  of  new 
bone,  which,  however,  remains  imperfectly  calcified.  The  process 
of  decalcification  begins  at  the  periphery  of  the  bone  trabeculae 
and  gradually  extends  to  the  deeper  parts.  The  Une  of  demarcation 
between  the  normal  and  diseased  bone  is  sometimes  even  and  con- 
tinuous, but  may  be  irregular  with  excavations  resembUng  Howship's 
lacunae.  There  may  be  an  intermediate  zone  in  which  the  Ume  salts 
are  not  completely  removed  but  remain  in  the  form  of  a  crumbling 
detritus.  The  periosteum  is  likely  to  be  thickened  and  vascular 
and  the  medulla  resembles  that  of  infancy  in  its  gross  appearance. 
Spontaneous  fractures  and  various  distortions  may  occur  in  osteo- 
malacia and  the  thorax  is  apt  to  be  flattened  laterally.  Osteo- 
malacia is  recognized  chnically  in  children  as  a  rare  condition,  but 
it  has  not  yet  been  proved  that  it  may  not  occur  as  a  disease  of  the 
new-born.  No  modern  and  exact  histologic  examinations,  how- 
ever, have  been  made  of  infants  at  birth  which  have  shown  the 
pathology  of  the  osteomalacia  of  post-natal  cases,  and  it  is  still 
uncertain  as  to  how  early  this  condition  may  appear.  It  has  there- 
fore been  thought  better  to  provisionally  classify  osteomalacia  with 
diseases  of  nutrition,  although  such  classification  is  manifestly 
empirical.  Cases  examined  by  the  Roentgen  method  give  a  notice- 
able and  characteristic  picture.  The  general  development  of  the 
skeleton  is  normal.  The  bones  are  generally  a  Uttle  longer  and  a 
little  narrower  than  normal,  with  or  without  deformity  or  fractures. 
Usually  one  or  more  fractures  of  the  bones,  commonly  the  femur, 
are  found,  which  fail  to  unite,  and  a  deformity  results  from  super- 


98  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

incumbent  weight.  At  the  point  of  fracture  very  little  formation  of 
new  bone,  represented  by  a  callus,  will  be  seen,  though  at  certain 
portions  of  the  bones  there  will  be  a  very  dense,  definite  cortical 
bone  giving  the  so-called  pencilled  outline.  Marked  increased 
radiability  of  certain  portions  of  the  bones  is  seen.  The  irregular 
cortex,  with  more  or  less  osteoid  tissue,  is  apparent  without  any 
great  change  in  the  medulla  or  in  the  structure  of  the  bone  except- 
ing a  lack  of  density.  The  knowledge  which  we  have  derived  from 
studying  the  living  pathologic  anatomy  in  these  cases  is  simply 
what  we  should  expect  from  the  post-mortem  findings,  namely,  that 
it  is  a  condition  of  osteoporosis,  which  accounts  for  the  increased 
radiability  and  corresponds  to  the  low  atomic  weight.  According 
to  Buck  and  Bryant  the  Roentgenographic  pictures  present: 

Cystic  formation  with  medullary  and  cortical  destruction. 

Acute  bowing  and  angular  bending  of  the  bones. 

Large  amount  of  partly  calcified  callus  and  cartilage  at  the 

seat  of  a  spontaneous  fracture. 
Diminution  of  lime  salts. 

Our  experience  at  the  Children's  Hospital  leads  us  to  believe 
that  many  of  the  details  of  the  Roentgenographs  of  living  cases  of 
osteomalacia  correspond  to  those  seen  in  osteogenesis  imperfecta, 
but  the  dead  pathology  shows  the  two  diseases  to  be  very  different. 

Plate  74  shows  the  photograph  of  a  girl  seven  years  old  with 
the  general  clinical  signs  of  osteomalacia.  Especially  to  be  noted  in 
Fig.  2  is  the  bowing  of  the  upper  part  of  the  left  femur.  Ever  since 
the  child  was  able  to  walk  there  had  been  a  tendency  to  bending  of 
the  extremities  without  adequate  apparent  trauma.  Fracture  or 
something  closely  allied  to  it  had  been  suspected  in  the  right  femur, 
but  nothing  definite  was  detected  until  the  Roentgenograph  dis- 
closed the  condition  shown  in  the  plate. 


DISEASES  OF  NUTRITION.  99 

Fig.  1  shows  where  a  break  in  continuity  was  found  in  the 
upper  part  of  the  shaft  of  the  right  femur  without  the  callus  or  a 
lesion  which  would  be  found  in  the  fracture  of  a  normal  bone.  In 
the  same  region  on  the  left  side,  as  is  seen  in  the  plate,  there  is  a 
decided  bending.  A  coarse  arrangement  of  the  structure  of  the 
bone,  with  increased  absorption  of  lime  salts,  is  seen  in  the  neck  of 
the  left  femur. 

INFANTILE  ATROPHY 

A  condition  of  the  tissues  called  infantile  atrophy,  which  is 
essentially  one  of  infancy  and  early  childhood,  and  most  com- 
monly occurs  in  the  first  six  months  of  life,  is  usually  classified 
among  the  diseases  of  nutrition.  No  specific  pathologic  lesions 
have  been  found  in  these  cases.  They  merely  show  extreme 
anaemia  of  all  the  soft  tissues  without  demonstrable  disease  of  any 
of  the  organs.  It  has  been  thought  possible  that  infantile  atrophy 
is  merely  a  form  of  starvation.  Starvation,  however,  even  in  its 
most  aggravated  forms,  in  most  cases  quickly  responds  to  special 
manipulation  of  the  food,  while  infantile  atrophy  shows  such  resist- 
ance to  all  kinds  of  treatment  and  to  all  manipulation  of  the  food 
that  at  present,  although  ignorant  of  the  cause  of  the  disease, 
beyond  its  possible  connection  with  food,  I  assume  it  as  an  entity. 
Roentgenographs  show,  so  far  as  I  have  been  able  to  determine 
by  a  careful  study,  nothing  which  has  not  already  been  determined 
at  autopsies,  that  is,  we  are  still  absolutely  ignorant  of  the  etiology 
of  infantile  atrophy,  and  know  nothing  of  its  pathology  beyond  a 
wasting  of  all  the  tissues. 

Plate  75,  Fig.  1,  is  the  photograph  of  a  girl  about  twelve  months 
old.  The  progressive  and  extreme  emaciation  and  the  resistance 
to  all  of  the  most  approved  modern  methods  of  feeding  of  this 
class  of  cases  showed  that  it  was  not  a  simple  case  of  starvation. 
(For  a  discussion  of  this  condition  see  "  Pediatrics,"  5th  ed.,  p.  341.) 


100  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Fig.  2  is  the  Roentgenograph  of  this  same  case.  The  lower 
half  of  the  femur,  the  knee,  and  the  tarsal  bones  are  shown.  To 
be  noted  are  the  clear-cut,  smooth  epiphyseal  lines  of  a  perfectly 
normal  condition.  The  cortex  is  possibly  somewhat  more  dense 
than  normal,  as  shown  by  a  certain  amount  of  decreased  radiability, 
but  there  is  nothing  sufficiently  marked  to  allow  us  with  the  present 
knowledge  which  we  possess  of  interpretation  to  make  the  diagnosis 
of  infantile  atrophy  from  the  Roentgenograph,  although  the  clinical 
aspect  of  the  case  readily  makes  the  diagnosis. 

The  differential  diagnosis  from  general  tuberculosis  is  at  times 
exceedingly  difficult,  so  that  Roentgen  evidence  if  present  is 
extremely  valuable. 

SCORBUTUS 

Scorbutus,  as  it  manifests  itself  in  early  life,  and  usually  in  the 
first  year  and  a  half,  is  closely  related  to  the  scorbutus  of  later  Ufe. 
It  is  a  constitutional  disease  closely  associated  with  imperfect  nutri- 
tion, and  plays  so  definite  a  role  in  infancy  that  it  is  usually  accepted 
as  a  special  disease  of  infancy.  It  is  characterized  by  anaemia 
and  a  tendency  to  hemorrhage,  and  in  most  cases  is  accompanied 
by  a  condition  of  the  gums  which  is  present  in  stomatitis  ulcer- 
osa, the  latter  condition,  however,  only  occurring  when  teeth  are 
present.  The  tendency  to  hemorrhage,  although  it  may  be  from 
any  organ,  is  in  most  cases  so  common  in  the  bones  that  the  use  of 
the  Roentgen  ray  in  determining  the  disease  becomes  invaluable. 
There  may  be  deep  hemorrhages  into  the  muscles  and  occasionally 
about  or  into  the  joints,  but  the  hemorrhage  is  essentially  subperios- 
teal and  confined  chiefly  to  the  long  bones.  The  femora  are  most 
commonly  affected  and  there  is  a  tendency  to  separation  of  the 
epiphyses.  It  is  the  subperiosteal  hemorrhage  of  greater  or  less 
extent  which  when  recognized  in  the  Roentgenograph  aids  us  in 
making  a  differential  diagnosis  from  other  diseases,  which  manifest 
their  primary  lesions  in  other  parts  of  the  bones.    We  should  notice 


DISEASES  OF  NUTRITION.  101 

first  whether  there  is  a  greater  or  less  area  of  fatty  tissue,  or  whether 
or  not  there  is  infiltration.  Second,  we  should  examine  the  muscles 
as  to  whether  they  are  infiltrated,  atrophied,  hypertrophied,  or 
present  a  clearly  defined  outline.  Third,  we  should  observe  whether 
the  periosteum  can  or  cannot  be  seen  in  the  picture.  In  the  latter 
case  we  must  look  further  for  disease  by  examining  the  cortex  of  the 
bone  and  finally  its  medullary  cavity.  If,  on  the  contrary,  the  peri- 
osteum can  be  seen  we  must  determine  whether  we  are  deaUng  with 
a  thickened  periosteum,  or  with  a  periosteum  separated  from  the 
cortex.  In  the  latter  case  we  should  decide  whether  regeneration  of 
the  periosteum  and  bone  formation  has  begun  (as  this  is  the  process 
by  which  repair  takes  place),  or  whether  it  is  the  lessened  radiability 
of  a  fresh  exudation  beneath  the  periosteum.  If  we  find  that  there 
is  a  decided  bulging  of  the  periosteum,  and  a  certain  amount  of 
infiltration  of  the  surrounding  tissues,  we  are  led  to  suspect  that  we 
have  a  subperiosteal  effusion,  but  whether  it  is  blood  or  pus  the 
Roentgenograph,  according  to  our  present  interpretation,  does  not 
tell  us.  The  symptoms  differ  greatly  according  as  an  acute  pain- 
ful locahzed  condition  is  present,  depending  upon  the  rapid  process 
which  occurs  in  osteomyelitis,  or  whether  the  condition  is  the  slow, 
subacute  clinical  sequence  of  an  essentially  chronic  constitutional 
disease  such  as  scorbutus.  In  the  latter  case  acute  pain  is  usually 
absent  if  the  affected  part  is  not  disturbed.  If  the  diagnosis  of 
scorbutus  has  been  made  the  Roentgenograph  will  when  taken 
from  time  to  time  show  whether  the  pathologic  process  is  increasing 
or  diminishing.  It  will  also  show  the  degree  to  which  the  periosteum 
has  been  stripped  from  the  cortex  and  whether  it  has  begun  to 
invade  a  joint.  All  this  knowledge  acquired  by  the  Roentgen  ray 
is  of  the  greatest  importance  in  the  treatment  both  medically  and 
surgically.  The  recognition  by  the  Roentgenograph  of  a  scorbutus 
which  shows  itself  under  the  periosteum  of  the  hip  is  especially 
valuable,  as  it  saves  the  infant  from  the  excruciating  pain  which 


102  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

movement  of  any  kind  produces.  It  tells  the  surgeon  that  he  is  not 
dealing  with  a  case  of  osteomyelitis  or  of  tuberculosis,  or  possibly 
of  a  number  of  other  infections,  and  enables  him  to  avoid  the  neces- 
sary^ and  painful  manipulations  which  he  would  otherwise  employ  in 
determining  whether  the  hip  was  affected.  The  same  reasoning 
can  be  carried  out  when  the  other  joints  are  affected.  I  would 
especially  add  that  the  differentiation  of  the  enlarged  wrist  of  scor- 
butus from  that  of  rhachitis,  and  also  from  syphilis,  by  the  Roentgen 
method  is  of  the  greatest  diagnostic  value  and  can  be  accomplished 
without  harm  to  the  infant.  Again,  the  differentiation  from  a 
possible  fracture  is  made  with  certainty  and  without  pain,  or  a  sus- 
pected separation  or  break  in  the  region  of  the  epiphysis.  In  some 
cases  most  serious  mistakes  have  been  avoided  by  the  use  of  the 
Roentgen  ray.  Various  operative  procedures,  and  even  amputa- 
tion of  the  thigh  for  sarcoma,  have  been  given  up  because  the  ray 
has  shown  that  the  surgeon  was  not  dealing  with  a  sarcoma,  but  with 
a  large  organized  subperiosteal  effusion  which  simulated  sarcoma. 
In  some  of  these  cases  the  tissues  were  found  to  be  enormously 
infiltrated  and  hardened  so  that  the  tissue  of  the  thigh  assumed  the 
appearance  of  a  new  growth.  Instances  of  this  class,  which  are  only 
examples  of  what  may  occur  in  any  part  of  the  osseous  system, 
have  come  under  my  notice  quite  a  number  of  times,  and  in  these 
cases  after  the  differential  diagnosis  by  the  Roentgen  method  had 
been  made  the  infants  rapidly  recovered  under  no  other  treatment 
than  the  prompt  and  free  administration  of  orange  juice. 

Plate  76,  Fig.  2,  shows  the  photograph  of  a  girl  eleven  months 
old  with  scorbutus.  Note  the  enlargement  of  both  femora,  espe- 
cially the  upper  part  of  the  left  femur.  The  disease  had  been  going 
on  for  some  months  and  the  diagnosis  of  sarcoma  was  made  at 
a  consultation  of  surgeons.  The  infant  was  extremely  pale  and 
there  was  oedema  of  the  feet  and  lower  legs,  with  extreme  tenderness 
on  pressure  of  the  hips,  knees,  and  ankles.    The  upper  part  of  the 


DISEASES  OF  NUTRITION.  103 

left  thigh  showed  a  diffuse  hard  mass  involving  all  the  tissues.  There 
was  no  fluctuation  even  on  deep  palpation.  There  was  a  rapid  re- 
covery after  the  administration  of  orange  juice. 

Fig.  1  represents  a  Roentgenograph  of  this  case,  and  should  be 
compared  with  Plates  163  and  164,  Division  IX,  sarcoma  of  the 
thigh.  The  swelling  and  lack  of  clear  definition  of  the  muscles  of 
both  thighs  is  marked,  and  the  irregular  toothed  appearance  of  the 
diaphyseal  and  in  some  places  epiphyseal  outline  is  accentuated. 
Note  the  roughened  appearance  of  the  zone  of  proliferation  in 
contradistinction  to  the  smooth-edged  zones  in  Plate  75,  infantile 
atrophy. 

Plate  77  represents  the  same  case  in  a  late  stage  and  shows 
the  organization  of  the  clot  considerably  advanced.  The  thickened 
periosteum  and  the  line  of  hemorrhage  can  easily  be  distinguished 
in  the  femora  and  in  the  tibiae.  The  epiphyses  are  irregular  and  the 
picture  shows  us  that  rhachitis  is  also  present.  Note  here  also  the 
absolute  dissimilarity  of  these  epiphyses  and  zones  of  proliferation 
from  what  is  seen  in  the  case  of  infantile  atrophy,  Plate  75. 

Plate  78  represents  the  Roentgenograph  of  the  leg  of  an 
Infant  six  months  old.  There  is  considerable  involvement  of  the 
soft  parts  of  the  thigh,  and  the  subperiosteal  hemorrhage  is  easily 
iollowed  along  the  whole  length  of  the  shaft  of  the  femur.  The 
extent  of  the  hemorrhage  along  the  line  of  the  tibia  is  even  more 
marked  than  in  the  femur.  There  is  no  especial  change  in  the  shaft 
jf  the  bone,  but  the  zone  of  proliferation  is  somewhat  irregular. 

Plate  79  represents  the  same  subject  as  Plate  78. 

Plate  80  shows  an  infant  two  months  old.  The  infant  was 
normal  at  birth,  and  had  always  been  fed  from  the  breast.  The 
parents  were  healthy,  and  the  mother  apparently  well  at  the  time  of 
nursing.  The  swelling  and  tenderness  first  appeared  in  the  right  arm 
and  then  involved  the  lower  extremities.  The  left  arm  was  slightly 
affected.    The  infant  seemed  to  have  considerable  pain.    It  showed 


104  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

evidence  of  no  other  disease.  There  was  marked  thickening  of  the 
periosteum  of  both  lower  extremities  ;  this  condition  is  shown  in  the 
Roen  tgenogr  aph . 

RHACHITIS 

The  condition  which  in  diseases  of  nutrition  plays  the  greatest 
role,  in  that  we  find  it  associated  with  a  large  number  of  other  dis- 
eases, is  rhachitis.  It  is  chiefly  characterized  by  a  local  or  a  general 
disturbance  of  the  normal  process  of  ossification,  but  exactly  how  the 
hygienic  and  dietetic  causes,  which  are  supposed  to  produce  these 
osseous  changes,  accomplish  their  results  is  still  unknown.  The  uni- 
form and  definite  changes  in  the  bones  in  rhachitis  lead  us  to  con- 
sider it  a  disease  by  itself,  and  one  which,  although  connected  with 
nutrition,  is  not  wholly  a  form  of  malnutrition.  The  pathologic 
lesions  of  rhachitis  are  represented  chiefly  in  the  bones  and  occur 
during  the  period  in  which  the  normal  processes  of  ossification  are 
most  active,  that  is,  during  the  first  year  and  the  first  part  of  the 
second  year  of  life.  The  normal  growth  of  bone  depends  upon  three 
conditions :  (a)  Multiplication  of  cartilage  cells  in  definite  lines,  (b) 
followed  by  calcification  of  the  intercellular  spaces  for  the  entrance 
of  blood-vessels  with  specific  absorption  of  tissue,  and  (c)  finally  the 
concentric  deposition  of  bone  within  the  medullary  spaces.  The 
bones  grow  in  length  by  the  production  of  bone-tissue  in  the  carti- 
lage towards  the  epiphysis  and  the  diaphysis,  and  in  thickness  by 
the  growth  of  bone  from  the  inner  layer  of  the  periosteum.  At  the 
same  time  the  medullar}^  canal  is  enlarged  in  proportion  to  the 
growth  of  the  bone  by  the  absorption  of  its  inner  layer.  These 
processes  progress  in  definite  order  and  in  clearly  defined  zones. 

In  rhachitis  the  chief  microscopic  features  are  the  changes  which 
occur  in  the  zones  of  growth  and  the  asymmetrical  character  of  the 
prohferative  processes.  The  cartilaginous  and  subperiosteal  cell- 
growth  which  produces  ossification  goes  on  with  increased  rapidity 
and  in  an  irregular  manner  both  between  the  epiphysis  and  the 


DISEASES  OF  XUTRITIOX.  105 

diaphysis  and  beneath  the  periosteum.  If  we  examine  microscopi- 
cally the  region  between  the  epiphysis  and  the  diaphysis,  usually 
called  the  zone  of  proliferation,  we  find  that  the  cartilaginous  cells 
are  not  regularly  arranged  in  rows  around  a  definite  zone  in  advance 
of  the  ring  of  ossification,  as  in  normal  tissue.  On  the  contrary 
there  is  an  irregular  heaping  up  of  cartilaginous  cells,  sometimes  in 
rows,  sometimes  not,  covering  an  ill-defined  irregular  area.  This 
zone  of  proliferation  also,  instead  of  being  narrow  and  sharply  de- 
fined, is  quite  lacking  in  uniformity.  It  presents  a  broad,  reddish- 
gray  appearance,  with  marked  thickening  and  hyperaemia.  The 
medullary  spaces  are  much  more  vascular  than  normal,  and  are  so 
increased  in  area  as  to  extend  into  the  zone  of  calcification,  and 
sometimes  through  it.  The  deposit  of  bone-tissue  within  these 
spaces  is,  however,  either  absent  or  very  irregular,  and  is  for  the 
most  part  replaced  by  a  soft,  friable  substance,  consisting  of  a 
bone-tissue  that  is  very  lacking  in  lime  salts,  with  cells  of  various 
kinds  embedded  in  a  fibrillated  ground-substance.  This  tissue  is 
called  "osteoid,"  and  is  similar  to  that  formed  by  osteoblasts. 

In  the  region  of  ossification  (ends  of  diaphyses  and  epiphyses) 
there  is  microscopically  a  pronounced  increase  of  blood-vessels  and 
cartilage-cells,  with  lengthening  of  cell  columns,  and  disturbance  of 
calcification  of  the  intercellular  substance.  Calcification,  if  present, 
may  be  isolated  in  the  region  of  the  proliferating  cartilaginous  cells, 
or  may  be  altogether  absent  over  considerable  areas.  The  subperios- 
teal layer  of  cells,  which  is  normally  thin  and  scarcely  noticeable 
macroscopically,  becomes  hypersemic  and  thickened  with  an  appear- 
ance similar  to  that  of  spleen-pulp.  Beneath  this  periosteum  is  also 
to  be  found  the  "osteoid"  tissue  seen  in  the  zones  of  proliferation. 

The  medulla  of  the  bone  is  more  hypersemic  even  than  normal. 
Its  tissue  is  rich  in  cells,  and,  like  the  fetal  medulla,  contains  dilated 
vessels  and  fat.  The  intercellular  substance  may  show  mucoid 
degeneration  or  even  be  of  fluid  consistency.     In  such  a  condition 


106  THE  ROKXTGEX    KAY  I.\   IM'.DIATHICS. 

it  does  not  seem  that  lime  is  dissolved  from  the  bone-tissue  by  the 
blood,  but  that  it  is  the  resorption  of  such  bone  that  is  the  impoi-tant 
factor  in  the  process.  Resorption  at  the  age  at  whicli  rhachitis 
occurs  is  normal.  Pimmes,  especially,  believes  that  resorption  in 
rhachitis  is  not  increased.  Muller  and  \'irchow  seem  to  hold  tlie 
same  views,  while  Kassowitz  and  Ziegler  think  it  is  increased.  Clin- 
ically, certain  extremely  rapid  cases  of  softening  seem  to  show 
increased  resorption  (Vierordt).  Ordinarily,  with  a  resorption  not 
greatly  increased,  the  formation  of  fresh  bone  containing  but  little 
lime  results  in  loss  of  strength.  In  the  skull,  in  some  places,  absorp- 
tion pi-edominates  (occiput) ;  in  other  cases  accretion  of  osteoid  tis- 
sues (frontal  and  parietal  eminences).  Deficient  bone-growth  simply 
determines  open  fontanelles.  In  convalescence  Hme  is  deposited  in 
the  previoush^  limeless  osteoid  tissue,  and  the  result  is  a  thick  and 
heavy  bone.    In  fractures  at  this  period  callus-formation  is  excessive. 

An  excessive  proliferation  of  cells  in  the  inner  layers  of  the 
periosteum,  the  irregular  calcification  which  occurs  about  them, 
and  the  absence  of  uniformity  in  the  elaboration  of  the  structure  of 
the  bone,  produce  an  irregular,  spongy  bone-tissue  instead  of  the 
compact  lamellated  tissue  which  is  so  necessary  for  the  uniformity 
of  the  structure.  The  increased  cell-growth  between  the  epiphysis 
and  the  diaphysis  produces  the  peculiar  knobby  swellings  which  are 
characteristic  of  rhachitis.  At  the  same  time  the  medullary  cavity 
increases  rapidly  in  size,  and  the  inner  layers  of  the  l)one  become 
spongy.  The  result  of  these  processes  is  to  diminish  the  solidity  of 
the  bones  so  that  they  cannot  resist  the  strain  of  the  muscles  or 
outside  pressure.  After  a  time  the  rhachitic  process  may  stop  and 
the  bones  ma}'  assvnne  a  more  normal  character.  The  porous  bone- 
tissue  becomes  compact,  and  even  unnaturally  dense,  so  that  in 
later  childhood  the  rhachitic  bone  is  unusually  hard,  like  ivory,  a 
condition  noticed  by  those  who  have  to  operate  on  these  bones. 

Fig.   1   represents  a  section  of  a  normal  bone  taken  from  an 


DISEASES  OF  XUTRITIOX. 


107 


infant,  and  shows  the  normal  zone  of  proHferation  (Z.  P.)  between 
the  epiphysis  and  the  diaphysis. 

Fig.  2  represents  a  section  of  a  rhachitic  bone,  and  shows  the 
broad,  irregular,  and  abnormal  zone  of  proliferation  (Z.  P.). 


-/..  p. 


•  -/..  p. 


Fin.  1. — Normal  bone:   Z.  P.,  zone  of  proiiferatioD.         Fig.  2. — Ilhachitic  bone:   Z.  P.,  zone  of  proliferation. 

The  clinical  diagnosis  of  rhachitis  from  diseases  which  may  sim- 
ulate it  need  not  be  fully  stated  here.  A  few  words,  however,  may 
aid  us  in  making  the  best  use  of  our  Roentgen  picture.  In  chon- 
drodystrophia  foetalis  the  trunk  is  normal  while  the  extremities  are 
short  and  deformed.  The  enlargements  of  the  ends  of  the  long  bones 
are  due  to  overgrowth  of  the  periosteum,  instead  of  to  changes  in  the 
epiphyseal  cartilage,  and  the  zone  of  proliferation  is  narrower  than 
in  rhachitis.  In  rhachitis  there  is  an  absence  of  the  disproportion 
between  the  trunk  and  the  limbs  which  is  seen  in  chondrodystrophia 
fcetalis.  In  chondrodystrophia  foetalis  also  the  epiphyseal  lines  instead 
of  being  irregular  are  straight,  although  much  narrowed,  and  the 
shafts  of  the  bones  are  often  thick  and  striated.  The  characteristic 
symptoms  of  osteomalacia,  a  very  rare  disease  in  childhood,  do  not 


los  THE  K()i:.\Te;i:.\  kay  i.\  I'Luiatkics. 

appear  in  such  marked  degree  and  sequence  as  in  rhachitis.  Also  in 
osteomalacia  the  hick  of  hnie  salts  is  shown  by  the  degree  of  the  den- 
sity, and  is  usually  well  marked,  and  the  deformities  of  the  shafts  of 
the  bone  are  characterized  by  bending  rather  than  by  sharp  curves. 

The  differential  diagnosis  by  the  Roentgen  ray  is  (|uite  distinct 
and  characteristic,  and  according  to  Osgood  may  be  summarized  as 
follows:  In  rhachitis  there  is  great  irregularity  of  the  epiphj'seal 
lines  with  hyperplasia  of  the  osteoid  tissue  and  hypertroph\-  of  the 
epiphyseal  cartilage.  These  pathologic  changes  usually  give  th(> 
appearance  of  a  great  disproportion  between  the  bony  epiphysis 
and  the  epiphyseal  end  of  the  diaphysis.  The  curves  in  the  shafts 
of  the  bones  are  often  sharp.  In  chondrodystrophia  fcetalis  and  osteo- 
malacia the  abnormal  densities  are  seen  most  often  to  involve  the 
joints,  although  the  appearances  in  the  adjacent  bones  are  sometimes 
quite  characteristic.  They  represent  the  poorly  organized  condi- 
tion of  ill-nourished  bone  with  a  deficiency  of  lime  salts.  If  foci 
(areas  of  definite  necrosis)  appear  they  are  prone  to  involve  the 
epiphyses.  In  osteomj'elitis  the  abnormal  densities  are  to  be  seen 
in  the  diaphyses  and  are  generally  due  to  irregular  necrotic  areas, 
with  or  without  se(|uestra.  There  is  usually  no  lessening  of  the 
densities  of  the  involved  bone  or  surrounding  bones. 

The  changes  in  the  osseous  system  due  to  rhachitis  are  detected 
b}'  the  Roentgen  method  of  examination  before  it  is  possible  to  do 
so  b}'  the  clinical  examination.  The  primary  pathologic  changes  in 
rhachitis  occui'  in  the  parts  in  wliich  new  bone  formation  takes  place, 
the  periosteum  and  epiphyses,  and  these  can  be  classified  for  the  pur- 
pose of  Roentgen  study  and  description  as  follows: 

The  epiphysis  and  zone  of  proliferation. 
The  outline  of  the  cortex  and  periosteum. 
The  medullary  canal. 
The  general  structure  of  the  bone. 


DISEASES  OF  NUTRITION.  109 

The  changes  in  the  bones  of  rhachitis  are  varied,  although 
characteristic  of  the  condition. 

There  are  some  cases  in  which  at  any  age  from  birth  to  puberty 
marked  disturbances  of  the  zone  of  proliferation  take  place  and, 
though  the  case  may  not  be  recognized  pathologically,  yet  cUni- 
cally  it  presents  the  picture  of  a  severe  degree  of  rhachitis.  We 
often  find  by  examination  that  the  epiphyses  of  all  the  bones  are 
delayed  in  ossification,  that  they  are  smaller  than  they  should 
be  for  the  given  age,  and  that  there  is  such  a  lack  of  inorganic 
material  in  the  bone  that  it  gives  an  increased  radiabiUty.  The  zone 
of  proliferation  is  a  great  deal  wdder  than  normal,  with  irregular 
deposits  of  bone  on  the  epiphyseal  side,  so  that  we  get  a  "toothed 
appearance"  of  the  diaphysis  with  a  degree  of  radiabiUty  in  the 
zone  of  proliferation  which  is  more  Uke  that  of  cartilage  than  bone. 
There  is  usually  also  a  definite  thickening  of  the  periosteum.  The 
changes  in  the  bone  are  a  thinning  of  the  cortex,  with  an  irregular 
deposit  of  bone-cells  of  irregular  outUne,  an  increase  of  the  medul- 
lary cavity,  and  a  marked  re-arrangement  of  the  bone  structure. 
These  changes  go  on  to  such  an  extent  that  cystic  formation  of  the 
bone  at  times  becomes  apparent.  Marked  deformities  of  the  osseous 
system  may  not  alwaj's  be  present,  but  sooner  or  later,  according 
to  the  activity  of  the  child  and  the  progress  of  the  disease,  deformi- 
ties of  the  bones  take  place,  so  that  we  get  the  characteristic  bowing 
which  is  so  marked  cUnically.  Plate  87  illustrates  what  has  just 
been  said.  In  this  plate  it  is  to  be  noticed  that  the  substance 
of  the  bone  is  greater  on  the  concave  than  on  the  convex  side.  This 
is  usually  seen  in  the  middle  of  the  bone,  and  the  medullary  cax-ity 
of  these  cases  often  shows  areas  of  increased  radiability  and  appar- 
ently of  cystic  formation.  This  appearance  is  caused  by  areas  filled 
with  cartilage  or  osteoid  tissue  which  has  not  calcified. 

Fracture,  partial  or  complete,  may  be  seen  in  any  of  the  bones, 
and  very  Uttle  tendency  towards  callus  formation,  although  appar- 


no  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

entl}'  enough  to  make  the  bone  more  or  less  solid  (Plate  82).  At 
points  where  the  strain  becomes  great,  as  the  deformity  increases, 
an  effort  is  made  on  the  part  of  nature  to  prevent  the  bone  giving 
way  at  this  point  by  the  laying  down  of  new  bone-cells,  which  are 
readily  recognized  by  a  more  definite  re-arrangement  of  the  struc- 
ture of  the  bone  (Wolffs  Law,  Plate  84).  This  is  common  in  the 
lower  third  of  the  femur  and  the  tibia  in  cases  where  there  is  clini- 
cally knock-knee  or  bow-leg. 

There  are  other  cases  which  show  a  delayed  ossification,  a 
marked  increase  of  the  bones  in  size  with  no  great  change  in  the 
zone  of  proliferation,  and  in  addition  to  this  marked  deformity. 
Clinically  these  cases  show  an  enlargement  of  the  epiphyses  and  of 
the  diaphyses,  but  the  bones  generally  show  a  more  definite  change 
in  their  structure.  The  outline  may  be  irregular,  very  seldom  the 
periosteum  is  thickened,  and  the  cortex  is  thin  or  very  little  laid 
down.  There  is  a  marked  increase  of  the  medullary  canal,  with  a 
definite  change  of  the  structure  of  the  bone  and  a  coarse  re-arrange- 
ment of  bone  trabeculse.  The  epiphyses  in  these  cases  are  charac- 
terized by  symmetrical  enlargement  of  the  diaphyses  and  with  no 
apparent  changes  in  the  zone  of  proliferation. 

According  to  George  these  types  of  rhachitis  from  a  clinical 
point  of  view  are  not  distinguishable,  but  from  a  Roentgen  point  of 
view  are  quite  evident. 

Plate  81  shows  a  very  early  stage  of  rhachitis  in  a  child  three 
years  old.  The  shafts  of  the  femora  are  comparatively  normal  in 
structure  and  in  size.  If,  however,  we  compare  this  picture  with  the 
anatomic  conditions  seen  in  Plate  13,  a  normal  child  of  three  years, 
it  will  be  noticed  that  the  zone  of  proliferation  is  beginning  to  show 
a  disturbance  by  its  toothed  and  irregular  appearance.  The  epi- 
physeal cartilage  is  also  seen  to  be  broader  than  normal,  and  this  is 
seen  to  be  still  more  evident  if  we  compare  this  zone  of  proliferation 
with  that  of  the  case  of  infantile  atrophy  shown  in  Plate  75. 


DISEASES  OF  NUTRITION.  Ill 

Plate  82  shows  the  characteristics  of  a  typical  case  of  rhachitis 
in  the  leg  of  a  child  two  years  old.  The  periosteum  is  thickened 
in  several  places.  There  is  an  irregular  deposit  of  the  cortex  of 
the  bone,  especially  at  the  upper  ends  of  the  tibia  and  fibula.  The 
normal  striation  of  the  substance  of  the  bone  has  been  replaced  by  an 
irregular  formation  of  the  bone,  showing  itself  by  the  jagged  edges 
of  the  distal  ends  of  the  femur  and  tibia  and  of  the  epiphyseal  line. 
There  is  a  spontaneous  fracture  in  the  lower  part  of  the  femur. 
There  is  a  deficiency  of  lime  salts  shown  in  both  shafts  and  epiphyses, 
the  latter  being  surrounded  by  normal  epiphyseal  cartilage. 

Plate  83  shows  a  boy  seven  years  old  with  typical  rhachitis. 
Fig.  1  represents  the  typical  rhachitic  position  in  sitting,  and  the 
prominent  abdomen,  enlarged  wrists,  knees,  and  ankles  so  common 
in  rhachitis. 

Fig.  2  is  a  front  view  and  Fig.  3  a  side  \iew  of  the  same  case. 

Plate  84  represents  the  Roentgenograph  of  the  same  subject 
shown  in  Plate  83.  This  plate  shows  some  of  the  earUer  mani- 
festations of  rhachitis.  There  is  a  somewhat  more  marked  bowing 
of  the  tibia  and  fibula,  due  to  superincumbent  weight,  than  would 
be  expected  from  the  slight  alteration  of  structure  presented  in 
the  bones.  The  diaphyses  of  both  tibia  and  fibula  are  enlarged  as 
compared  with  their  shafts.  The  cortical  bone  is  thicker  on  the  con- 
cave side  of  the  shaft  at  the  part  where  the  deformity  is  greatest, 
which  is  in  accordance  with  Wolff's  law.  The  structure  of  the  bone 
is  considerably  coarser  than  normal,  especially  in  the  diaphyses. 
The  epiphyses  are  all  fairly  well  defined.  There  is  very  little  disturb- 
ance of  the  zone  of  proliferation,  which  shows  a  lessened  deposit  of 
Ume  and  increased  radiability. 

Plate  85  represents  a  typical  case  of  advanced  rhachitis  in  a  boy 
ten  years  old.  The  bones  are  increased  in  size  and  in  thickness. 
The  large  amount  of  newly-formed  bone  and  the  decreased  radia- 


112  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

bility,  especially  at  the  ends  of  the  bones,  are  in  striking  contrast 
with  the  lessened  radiability  of  the  shafts  with  their  areas  of 
irregular  formation  of  bone  and  their  lack  of  lime  salts.  Note 
the  areas  of  thickened  periosteum  on  both  tibiiB,  and  the  decided 
thickening  of  the  cortex  on  the  curved  sides  of  the  bones  in  com- 
parison with  the  convex  sides. 

Plate  86,  Fig.  2,  represents  the  photograph  of  a  boy  seven  years 
old,  showing  especially  an  extreme  bowing  of  the  lower  part  of  the 
tibia  and  fibula. 

The  Roentgenograph,  Fig.  1,  shows  a  marked  coxa  vara  with 
deformity  of  the  pelvis.  There  is  marked  symmetrical  increase  in  the 
size  of  the  bones.  The  upper  parts  of  the  bones  show  a  heavy  deposit 
of  cortical  bone,  especially  on  the  concave  side,  and  are  also  marked 
by  increased  radiability.  There  is  a  marked  irregularity  and  an 
indefinite  deposit  of  the  lime  salts,  a  condition  which  frequently 
occurs  in  rhachitis  and  which  results  in  an  increase  of  radiability  in 
certain  areas,  especially  in  the  lower  parts  of  the  femora  and  in  the 
marrow.  There  is  some  disturbance  of  the  zone  of  proliferation 
shown  by  the  cortical  bone  being  laid  down  in  a  somewhat  irregular 
manner.  The  leader  points  to  a  needle  which  was  accidentally  dis- 
covered in  the  soft  parts. 

Plate  87,  Fig.  1,  shows  the  photograph  of  a  boy  three  years  old 
with  a  protuberant  abdomen,  knock-knee,  and  enlargement  of  the 
ankle-joints. 

The  Roentgenograph,  Fig.  2,  of  the  same  case  shows  a  thinning 
of  the  cortex  with  increase  of  the  medullary  canal,  a  lack  of  lime 
salts  and  a  consequent  increased  radiability. 

Rhachitis  of  Adolescence.  —  At  about  the  age  of  puberty  in 
certain  individuals  the  phj^sical  signs  of  rhachitis,  with  the  excep- 
tion of  a  lesser  degree  of  epiphyseal  enlargement,  occur,  and  in  these 
cases  albuminuria  is  usually  present.    Cases  of  this  class  are  desig- 


DISEASES  OF  NUTRITION.  113 

nated  as  the  rhachitis  of  adolescence  or  late  rhachitis.  The  disease 
is  a  rather  common  one  and  is  characterized  clinically  by  genu  val- 
gum or  varum,  scoliosis,  or  nothing  more  marked  than  enlarge- 
ment of  the  epiphyses  and  of  the  diaphyses.  Some  authorities  claim 
that  this  condition  is  the  forerunner  of  osteomalacia.  The  charac- 
teristics of  the  disease  are: 

The  outUne  of  the  bone  is  usually  normal. 

The  size  of  the  bone  is  usually  normal. 

The  epiphyses  are  well  developed. 

The  zone  of  prohferation  presents  more  of  a  change  than  is 
present  in  normal  epiphyseal  cartilage. 

The  diaphyses  are  toothed  as  well  as  the  epiphyses  and  show  an 
irregular  deposit  of  bone-cells. 

Plate  88  shows  the  hands  of  two  boys,  each  thirteen  years  old. 
Fig.  2  is  normal  for  the  given  age  while  Fig.  1  shows  the  condition  of 
the  rhachitis  of  adolescence.  By  comparison  with  the  normal  hand, 
Fig.  2,  it  is  noticeable  that  there  is  a  characteristic  increased  radia- 
bility.  The  medulla  is  apparently  normal,  excepting  for  its  increased 
radiability.  The  structure  of  the  bone  is  coarser,  but  no  more  regu- 
larly deposited  than  that  seen  in  the  rhachitis  of  an  earUer  period, 
having  generally  coarser  yet  regular  bone  trabeculae. 

Plate  89  shows  the  hand  of  a  boy  twelve  years  old  with  the 
rhachitis  of  adolescence.  The  bones  show  a  thickening  of  the  peri- 
osteum along  the  phalanges,  and  a  sHghtly  greater  toothed  and 
ragged  appearance  of  the  zone  of  proliferation  than  in  the  case  of 
the  same  disease  just  spoken  of  (Plate  88).  It  also  shows  more 
cortical  substance  than  in  the  pre\nous  case. 

Intra-utcrine  Rhachitis  {Fetal  Rhachitis). — My  opinion  in  regard 
to  this  condition  has  been  stated  on  page  90,  Di\asion  III. 


PLATE  74. 
OSTEOMALACIA. 

Girl,  age  7  yeara.    (Reduced  52i%.) 

Fig.  1.  A  Roentgenograph  of  the  Pelvis  and  Legs. 

A.  Points  to  the  upper  third  of  the  right  femur. 

B.  Points  to  the  coarse  bone  structure  in  the  upper 

part  of  the  left  femur.  Just  below  this  is  a 
marked  bowing  with  evidence  of  a  previous 
fracture,  now  united.  The  bones  in  general 
show  an  irregular  deposit  of  cortical  bone. 

Fig.  2.  A  Photograph  of  the  Same  Subject. 

Showing  considerable  bowing  of  the  upper  third  of 
the  left  femur. 


FIG.  1  - 


PI.ATE  74 


FIG.  2. 


PLATIO  7.-). 

IXI  AXTILE  ATROPHY. 

Fig.  1.  Photograph  of  .\x  Inf.\.nt,  Ack  12  Months. 

Fig.  2.  .\  Roentgenograph  of  the  .S.\me  Suhject. 

Shows  the  clear-cut  outline  of  the  hone.';.     The  texture  of 
the  bones  shows  nothing  that  would  be  called  abuornial. 


FIG.     2.        PliATE   To 


FIG.     1. 


1 


PLATE  70. 
IXIAXTILE  SCORBUTUS. 

Girt,  ajrc  II  iiu>iith>      (Kctluced  4'»9t .)     (Same  subject  as  Plate  77.) 
Fig.    1.    .\  KoENTGENOIiHAI'lI    (IF  THK    LoWEK    EXTREMITIES. 

^4.  Slightly  lliickciicd  cortt'x. 

B.  Slijihtly  thifkfui'il  pcrioslciuii. 

C  and    /).    Areas  (if  infiltrati'd  tissue. 

Fig.  2.   A  Ph(it(igk.\.1'h  gf  the  S.v.me  Sfuject. 


FIG.  1  . 


Plate  Hi 


IM.ATK  77. 
IXFA.VTILE  SCORBUTrs. 

Ciirl.  ai;.    II  monllw.     (Reduced  40%.)     (Same  subji-c-t  as  Plate  70.) 

.1 .  Oigiiniziug  clot  following  hemorrhage. 
B.  Thickened  periosteum. 

The  epiphyses  of  the  knees  ami  ankles  are  ))i'esent  hut  show 
less  tlensity  than  normal. 

Zone  of  proliferation  irregular. 


Plate  77 


PLAT1-:  -s. 

IXl'AXTILE  SCOKHLTUS. 

Age  i;  mom  lis.     (Reduced  12%.)     (Same  .subject  as  Plate  7!1.) 

.1.  Thickened  periosleuiii. 

/>.   Orjianizing  clot. 

C   IIu'm;\toma  of  the  mu.-<cli'.s  of  the  thi-:h. 


PliATK   78 


X 


■%v 


^■. 


m 


PLAT]:  70. 
INFANTILE  SCORBUTUS. 

(Reduccil  51%.)     (Same  subjecl  us  Plate  7S.) 

A.  Thickened  periosteum. 

Ji.  Orgiinizing  clot. 

('.  Tn-('gular  zone  of  luolifcration. 

J).  Ihcinatoniii  of  the  iimsclcs  of  the  thiiili. 


Platk  79 


PLATE  SO. 
INFANTILE  SCORBUTUS. 

Age  2  mcmlhs.     (Life  size.) 

.4  and  B.  Tliickciird  pcriostodm. 
C  and  I).   Infiltrated  niusclc. 


Platk  80 


PLATE  SI. 

KARI.Y  UIIACIIITTS. 

Age  3  years.    (Reiluced  2>iSi) 

The  arrow  |i(iiiits  towards  an  irregular  zone  of  pi'olifcration. 


Platk  81 


PLATE  S2. 

1:A1!LY   KllACIllTIS. 
Age  2  years.     (Reduced  12%. ) 

.1.  Slightly  thickened  ]ioriosteum. 

/).   Irregularly  ossified  cortex. 

C.   Partial  fracture  of  lower  third  of  femur. 


Plate  82 


#' 


// 


IM.ATK  S3. 
Ull  ACIIITIS. 

(Same  subject  as  Plat«  84.)    Boy.  ai^e  7  yeans. 

Fig.  1.  Tyi'Ic.m.  Picti'ke  when  Sitti.ni;. 

1"k:.  2.   HowiNG   OF   Right  Arm,    Flat-fuot.    Relaxation   of 

K.XEE-.IOINT. 
I'lG.  '.].    PkOMINE.VT  AuUO.MEN,    ExLAKGED     I'ilMl'HYSE.S. 


FIG.  1. 


PI.ATE  s:i 


FIG.   2. 


FIG  3. 


PLATE  84. 
EARLY    RHACHITIS. 

Hoy.  age  7  years.     (Redueed  ItU^.)     (Same  subject  as  Plate  83.) 

A.  Thickeiu'cl  cortox  (Wolff's  law). 

B.  Absorption  of  liini'  suits  of  the  (luijihysis  of  the  tibia. 

C.  Decreased  density. 


Plate  84 


PLATE  85. 

ADVANCED  RHACHITIS. 

Boy,  age  10  years.    (Reduced  50%.) 

Great  disturbance  of  the  structure  of  the  hones. 
Tliickcni'd  cortex  of  concave  sides  of  tlie  tibia;. 


Pi. ATE  85 


I'l-ATi:  S6. 

MAliKi:!)  lillACIHTIS. 

Roy,  ii're  7  years.    (Ueduci-.l  :j3i%.) 

Fk;.  1. — Pel\is  A\n  Fkmoha. 

The  Roentgenoo-raph  shows  cspocially  the  absorption  of  the 
lime  salts  in  the  upper  epiphysis  of  the  femur,  with  marked  irreg- 
ularity in  the  structure  of  the  bone,  and  a  marked  coxa  vara. 
Note  the  greatly  decreased  density  in  the  lower  part  of  the  fem- 
ora, the  beak-shaped  outline  of  the  cavity  of  the  pelvis,  and  the 
deformed  ilia  with  a  great  irregularity  of  the  structure  of  the  bone. 

.1.   Points  to  heavy  deposit  of  cortical  bone. 

The  arrow  points  towards  a  foreign  body,  a  needle  wliicli 
was  accidentally  found  at  the  examination. 

Fig.  2.  Photogr.\i'ii  ok  thk  S.wie  SrnjKCT. 

Shows  a  marked  (Icfoi'niity  from  Ijowing  of  llie  legs. 


FIG.  1. 


Plate  86 


f 


'^'■i 


V 


PLATIO  S7. 

Bi)\'.  atre  3  .\'ears.     (Reduced  25%.) 

Fill.  1.   PiiiiTocH Ai'ii    Showing    thf;    PuoTrHKUAxr    Ahihime.v. 
Kn(ick-knee,  and  Flat-foot. 

Fig.  2.  Roentgenograph  of  the  Same  Siimect. 

.1.    Marks  the  thifkoiKHl  jKM'iostcum. 

li.    Points  towiird  the  vciy  irrciiular  epiphyseal  Hue. 

C.  Thickened  periosteum. 


PliATE  87 


FIG.    2. 


PLATE  SS. 
RIIACIIITIS  OF  ADOLESCENCE. 

Hnnds  of  two  boys,  eacli  13  years  old.     (Reduced  26J%.) 

Fig.  1.   T!ii\(imic  ITwd. 

Tho  iijipor  arrow  points  towards  a  <jcneral  deviation  from 
the  normal  strurture  of  the  bone.  This  i.s  eviih-nt  in  tlie  wliole 
hand. 

The  lower  arrow  points  to  tlie  irrejiular  epiphyseal  line  of 
the  lower  ejiiphy.sis  of  the  radius. 

Fig.  2.  X(tK.M.\i.  li.'vxr). 


Plate  88 


PLAT]']  S9. 
RHACIIITIS  OF  ADOLESCENCE. 

Ace  12  years.      (Reduced  7$%.) 

^4.  Shows  Icssoiu'tl  density  of  cortex. 

B.  Slight  thiekening  of  periosteum. 

C.  Shirked  by  irregular  and  broad  zone  of  jiroliferation  show- 

ing the  lack  of  bone-forming  cells  and  an  increase  of  the 
cartilage  cells. 

D.  Sesamoid  bone. 


PliATE  89 


•■^- 


Is 


m 


Division  V 

DISEASES  OF  THE  HEAD  AND  SPINE 
HEAD 

There  are  comparatively  few  abnormal  conditions  of  the  head 
which  can  be  satisfactorily  recognized  by  the  Roentgen  method. 
In  tumors  of  the  brain,  where  there  is  a  reconstruction  of  the  tissues 
by  new  tissues  being  added,  or  where  there  is  less  tissue  than  normal, 
a  picture  representing  the  tumor  can  at  times  be  demonstrated. 
Where,  however,  there  is  the  same  amount  of  tissue  as  is  in  the  nor- 
mal brain,  a  very  small  amount  of  information  can  be  obtained  by 
means  of  the  Roentgen  ray.  We  at  times  have  been  able  to  detect 
a  tumor  of  the  brain  in  early  life,  and  have  had  under  our  care  at 
the  Children's  Hospital  a  case  of  this  kind  in  which  the  tumor  was 
located  by  means  of  the  Roentgen  ray.  Certain  results  of  trauma- 
tism, such  as  fractures,  play  an  important  role,  and  certain  infec- 
tions of  the  jaws  and  surrounding  tissues  can  often  be  diagnosticated 
definitely  only  by  means  of  the  Roentgen  ray.  Of  great  and  increas- 
ing value  is  the  aid  given  by  Roentgen  films  of  the  teeth.  By  their 
assistance  in  the  diagnosis  of  either  variations  or  anomalies  of  the 
teeth,  the  orthodontist  is  enabled  to  carry  out  his  work  with  a  pre- 
cision which  before  the  Roentgen  ray  could  be  applied  to  this  class 
of  cases  was  unknown.  As  in  the  study  of  other  parts  of  the  body, 
so  it  is  with  the  head,  that  to  understand  diseased  conditions  and  to 
intelligently  diagnosticate  and  treat  them,  a  knowledge  of  the  nor- 
mal conditions  is  essential.  We  must  be  able  to  say  whether  the 
different  sinuses,  frontal,  ethmoidal  or  sphenoidal,  are  in  a  normal 
or  abnormal  condition.  A  suspected  fracture  of  the  skull  can  be 
often  diagnosticated  only  by  means  of  the  Roentgen  method. 

As  an  example  of  this,  Plate  90  shows  a  fracture  of  the  skull 

115 


116  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

in  a  boy  thirteen  years  old.  This  fracture  was  not  recognized  cUni- 
cally  until  a  Roentgenograph  was  taken. 

Plate  91  shows  an  inflammatory  process  indicating  ethmoiditis 
in  a  child  three  years  old.  This  plate  also  shows  a  full  set  of  normal 
temporar}^  teeth. 

Plate  92  shows  how  important  it  is  to  have  the  temporary 
teeth  cared  for.  In  this  case  a  lack  of  care  of  the  mouth  and  teeth 
resulted  in  caries  and  suppuration  of  the  roots  of  the  teeth  and 
finally  an  osteomyelitis.  This  class  of  cases  arises  usually  from 
neglect,  and  oftener  from  this  cause  than  from  traumatism.  The 
legend  of  this  plate  shows  what  extensive  lesions  may  result  from 
osteomyelitis  of  the  jaw. 

The  anomalous  conditions  which  may  arise  in  connection  with 
the  teeth  in  early  life  are  very  numerous.  A  few  of  these,  however, 
will  be  sufficient  to  show  how  important  it  is  to  recognize  such  condi- 
tions when  present,  and  how  impossible  it  is  to  definitely  localize, 
diagnosticate  and  make  use  of  this  exact  knowledge  without  the  aid 
of  the  Roentgen  ray. 

Plates  93  and  94  show  the  sides  of  the  head  in  a  boj^  thirteen 
years  old.  The  value  of  obtaining  an  exact  knowledge  of  the  exist- 
ence and  position  of  an  unerupted  tooth  by  means  of  the  Roentgen 
method  is  obvious.  These  plates  show  the  second  lower  bicuspids 
wedged  between  the  first  and  second  molars.  Under  intelligent 
treatment  by  mechanical  means,  which  could  be  carried  out  when 
once  the  abnormal  position  of  the  teeth  was  determined,  the  abnor- 
mality was  corrected. 

Plate  93  shows  the  left  side  of  the  skull.  In  the  upper  jaw  the 
teeth  are  very  well  defined.  The  central  and  lateral  incisors  can 
readily  be  seen.  The  permanent  cuspid  does  not  show  very  clearly 
but  its  eruption  at  a  later  period  proved  its  existence.  The  un- 
erupted first   and  second   bicuspids   partly  calcified   can  be  seen 


DISEASES  OF  THE  HEAD  AND  SPINE.  117 

directly  above  the  temporary  molar,  the  roots  of  which  have  been 
absorbed,  leaving  them  about  to  be  exfoliated.  The  first  permanent 
molar  can  be  seen  completely  formed,  while  the  roots  of  the  second 
molar,  unerupted,  are  but  partly  calcified.  The  third  molar  does  not 
show  much  e\ndence  of  being  present,  although  there  seems  to  be  a 
sUght  outlining  of  the  crypt  in  which  its  formative  organ  lies  and 
the  beginning  of  calcification  of  the  tips  of  the  cusps. 

In  the  lower  jaw  the  crypt  of  the  third  molar  is  fairly  well 
defined  and  four  points  of  calcification  can  be  seen.  The  second 
molar  shows  clearly.  The  roots  are  partly  formed  with  wide  openings, 
large  pulp  canals  and  large  pulp  chambers.  A  comparatively  small 
amount  of  caries  at  this  period  of  development  might  have  involved 
the  pulp,  and  its  loss  through  irritation  would  be  more  serious  to  the 
future  usefulness  of  the  tooth  than  after  the  entire  calcification  of 
the  tooth  had  been  completed.  The  first  molar  shows  the  complete 
calcification  of  the  roots  with  much  smaller  pulp  canals  and  pulp 
chambers.  This  same  decrease  of  size  of  canals  and  pulp  chambers 
will  take  place  in  the  second  molar  during  its  continued  calcification. 

Anterior  to  the  first  molar  can  be  seen  the  reason  for  the  Roent- 
gen examination.  Here  lies  the  unerupted  second  bicuspid  tooth, 
held  in  this  position  by  the  forward  growth  of  the  first  and  second 
molars,  due  to  the  premature  loss  of  the  second  temporary'  molar, 
leaving  a  space  of  one-eighth  of  an  inch  between  the  crown  of  the 
first  permanent  molar  and  that  of  the  first  bicuspid.  The  root  is 
but  partly  formed  and  the  tooth  would  readily  erupt  if  it  had 
sufficient  space.  This  proved  to  be  true  later  when  space  had 
been  made  by  lengthening  and  widening  the  lower  arch.  The  same 
condition  existed  on  the  right  side  of  the  jaw,  which  is  shown  in 
Plate  94. 

Anterior  to  this  first  bicuspid  is  a  cuspid  which  is  just  erupting. 
Anterior  to  this  tooth  the  teeth  are  indistinct.    A  Roentgenograph 


118  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

of  this  size  is  not  satisfactory  for  determining  the  position  or  con- 
dition of  the  individual  teeth  anterior  to  the  second  bicuspids.  A 
small  film  placed  inside  the  mouth  gives  a  much  clearer  view  of  the 
point  of  interest,  and  by  this  means  we  are  not  confused  by  the 
teeth  on  the  other  side  of  the  jaw. 

Plate  95  shows  the  erupted  first  permanent  molars  and  some 
of  the  unerupted  teeth  in  a  boy  eight  years  of  age. 

In  the  upper  jaw  the  teeth  are  shown  to  be  in  an  abnormal 
condition  of  calcification  and  eruption.  The  picture  shows  the 
right  central  incisor  unerupted  and  the  root  partly  calcified.  The 
permanent  lateral  incisor  has  just  appeared  through  the  gum 
and  its  root  is  also  partly  calcified.  The  permanent  cuspid  lies 
posterior  to  the  lateral  incisor,  which  has  just  appeared  through 
the  gum,  and  its  root  is  only  partly  calcified.  The  first  bicuspid 
is  only  partly  calcified  and  its  root  not  entirely  formed.  The 
space  between  this  tooth  and  the  lateral  incisor  is  not  sufficient  to 
allow  the  cuspid  to  erupt  in  a  normal  position.  Posterior  to  the 
first  bicuspid  root  lies  the  second  bicuspid,  with  only  its  crown  cal- 
cified. Below  are  the  roots  partly  absorbed  and  what  is  left  of  the 
carious  crown  of  the  second  temporary  molar.  The  first  perma- 
nent molar  lies  posterior  to  this  tooth  and  appears  well  formed  and 
fully  erupted.  Posterior  to  the  roots  of  this  tooth  lies  the  second 
permanent  molar,  with  only  its  crown  formed.  There  are  no  signs 
whatever  of  the  third  molars  in  either  the  upper  or  lower  jaw. 

In  the  lower  jaw  from  behind  forward  is  the  second  molar  in  its 
crj'pt  with  its  crown  calcified.  Next  in  front  is  the  first  molar  fully 
erupted,  with  the  apices  of  its  roots  not  as  yet  calcified.  Next  in 
front  of  this  is  the  second  bicuspid  in  its  crypt  with  the  calcification 
of  its  root  not  begun.  Above  this  is  the  carious  crown  of  the  second 
temporary  molar.  The  next  anterior  tooth  is  the  first  bicuspid  just 
showing  its  crown  through  the  gum.    Its  root  is  but  partly  formed. 


DISEASES  OF  THE  HEAD  AND  SPINE.  119 

Immediately  above  are  the  outlines  of  the  teeth  in  the  opposite  side 
of  the  upper  jaw,  and  they  are  not  considered  in  this  description. 
Next  can  be  seen  the  fonn  of  the  unerupted  and  partly  formed  cus- 
pid, the  crown  of  the  temporary  cuspid  lying  above  and  a  little  in 
front.    Its  root  is  nearly  absorbed. 

The  inferior  incisors  have  all  erupted  but  are  in  malposition. 
This  is  not  shown  very  clearly  from  this  view. 

Supernumerary  teeth  play  quite  an  important  role  in  dentistry, 
since,  although  comparatively  rare,  they  may  occupy  space  needed 
for  the  proper  position  of  the  other  teeth. 

Plates  96,  97,  and  98  are  examples  of  this  kind  and  show  the 
great  value  of  Roentgen  examination. 

Plate  96  shows  the  left  side  of  the  skull  of  a  boy  fifteen  years 
old.  The  sinuses  are  well  developed.  The  teeth  are  very  well  shown 
in  the  upper  jaw,  but  in  the  lower  jaw  they  are  somewhat  confused 
on  account  of  the  presence  of  the  teeth  on  the  opposite  side. 

In  the  upper  jaw  the  central  and  lateral  incisors  are  fully  erupted 
and  the  cuspid  almost  in  position.  Just  above  the  lateral  incisor  is  a 
supernumerary-  tooth  unerupted.  The  first  and  second  bicuspids  are 
normal  and  fully  erupted.  The  first  and  second  molars  are  clearly 
defined.  The  third  molar  shows  beautifully  in  its  crj^t,  with  only 
the  crown  calcified  in  accordance  with  the  boy's  age.  The  lower 
third  molar  shows  a  similar  condition.  The  second  and  first  molar 
roots  do  not  show  clearly,  nor  do  those  of  the  second  and  first  bicus- 
pids, although  the  crowns  of  the  latter  are  well  marked  and  the 
pulp  canals  and  chambers  can  be  traced.  Anterior  to  the  first  bicus- 
pid the  teeth  are  not  distinct  enough  to  allow  of  any  accurate  de- 
scription. 

Plates  97  and  98  show  the  right  and  left  sides  of  the  skull  of  a 
girl  fourteen  years  old.  The  sinuses  are  normal  and  very  large  in 
both  plates. 


120  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

The  temporal  bones  and  the  glenoid  fossae,  in  which  lie  the 
condyles  of  the  inferior  maxilla,  are  clearly  defined. 

The  right  side  of  the  head  shows  the  superior  cuspid  retained  in 
its  alveolus  in  a  flat  position  (this  is  shown  better  in  the  film  print 
below) .  In  the  film  print  (looking  out  from  the  inside  of  the  mouth) 
the  superior  right  cuspid  lies  in  the  centre.  Back  and  to  the  right 
of  the  cuspid  and  partly  obscuring  it  is  the  first  bicuspid.  Then 
come  the  second  bicuspid  and  the  first  molar,  the  roots  of  the 
latter  not  being  so  clearly  defined  as  those  of  the  cuspid.  To  the 
left  of  the  cuspid  can  be  seen  three  incisor  teeth.  The  one  to  the 
extreme  left  is  the  right  central  incisor,  and  next  to  the  right  of  this 
tooth  is  a  supernumerary  tooth,  in  the  palatal  aspect  of  the  central 
and  lateral  incisors  the  next  tooth  to  the  right. 

There  is  nothing  of  interest  in  the  plate  until  we  come  to  the 
region  of  the  superior  second  molar.  This  tooth  is  indicated  by  the 
great  density  of  the  first  molar  and  the  tooth  which  is  a  super- 
numerary in  the  palatal  aspect.  Back  and  above  the  second  molar  is 
the  partly  calcified  and  unerupted  third  molar. 

In  the  lower  jaw  from  back  to  front  the  teeth  are  normal. 

Plate  98  shows  the  left  side  of  the  head.  The  superior  cuspid 
is  seen  in  a  somewhat  crowded  position.  The  film  below  shows 
the  tooth  much  more  plainly.  The  left  side  of  the  mouth  has  the 
same  anomalies  as  the  right,  with  the  exception  of  the  lack  of  a 
supernumerary  tooth  in  the  second  molar  region.  In  the  film  the 
tooth,  only  part  of  which  shows  in  the  lower  right-hand  corner,  is 
the  left  central  incisor.  The  next  tooth  to  the  left  is  a  supernumer- 
ary tooth  partly  obscured  by  the  left  lateral  incisor.  The  partly 
formed  third  molar  is  unerupted,  as  is  the  case  on  the  right  side. 

Plate  99  illustrates  the  value  of  the  Roentgen  method  of  exami- 
nation in  a  number  of  cases. 

Figs.  1  and  2  represent  the  mouth  of  a  child  fourteen  years 


DISEASES  OF  THE  HEAD  AND  SPINE.  121 

of  age.  Fig.  1  (the  left  side)  shows  the  absence  of  the  second 
bicuspid  (A).  The  accompanying  Fig.  2  shows  the  opposite  side 
of  the  mouth  which  also  lacks  the  second  bicuspid.  The  crown 
of  the  second  temporary  molar  is  still  in  place,  although  the 
absorption  of  the  greater  part  of  the  root  has  taken  place  without 
the  formation  of  the  permanent  teeth  underneath  it. 

Fig.  3  shows  the  mouth  of  a  child  thirteen  years  old  with 
the  absence  of  the  second  bicuspid.  The  temporary  molar  has 
remained  in  the  mouth  with  no  absorption  of  its  roots. 

Fig.  4  shows  an  interesting  picture  with  possibly  a  super- 
numerary tooth.  It  will  be  seen  that  the  cuspid  (B)  lies  in  the 
upper  left-hand  portion  of  the  picture;  immediately  beneath  it 
is  the  lateral  incisor  (C),  and  immediately  beneath  the  lateral 
incisor  and  a  little  in  front  of  it  is  the  crown  of  the  temporary 
lateral  incisor  or  possibly  a  supernumerary  tooth  (D).  Lying 
directly  back  of  the  central  tooth,  which  is  the  lowest  tooth  on 
the  plate,  lies  a  temporary  cuspid  (E),  and  immediately  above  it 
is  the  permanent  first  bicuspid  (F).  Back  of  this  temporary 
cuspid  root  lies  the  crown  of  the  first  temporary  molar.  It  will 
be  seen  that  the  permanent  central  incisors  are  in  malposition,  as 
are  also  the  lateral. 

Fig.  5  shows  the  superior  cuspids  lying  in  the  palate  directly 
behind  the  central  incisors.  It  was  found  that  the  apices  of  their 
roots  were  in  normal  position.  These  teeth  are  now  being  moved 
into  place. 

Fig.  6  shows  the  upper  jaw  of  a  girl  nine  years  of  age.  The 
plate  is  read  from  right  to  left.  In  the  right  upper  corner  is  seen 
the  tip  of  the  right  permanent  cuspid,  and  after  this  come  the 
permanent  central  incisors.  There  is  an  entire  absence  of  perma- 
nent lateral  incisors  in  this  jaw.  The  temporary  left  lateral  incisor, 
next  to  the  left  central  incisor,  has  its  root  almost  entirely  absorbed. 


122  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

and  above  it  is  the  permanent  cuspid  {H)  somewhat  rotated. 
Behind  the  temporary  lateral  incisor  is  the  temporary  cuspid  (/) , 
and  behind  this  tooth  are  the  first  and  second  temporary  molars. 
The  angle  at  which  the  film  was  exposed  does  not  allow  the  amount 
of  absorption  of  the  roots  of  these  teeth  to  be  shown,  but  the 
crowns  of  the  first  and  second  bicuspids  (J  and  K)  can  be  seen 
directly  above  them. 

Fig.  7  shows  the  mouth  of  a  child  eight  years  of  age  with  the 
temporary  cuspid  and  the  first  and  second  molars  in  place.  Above 
these  are  the  permanent  teeth  developing  and  erupting.  This  plate 
shows  very  clearly  the  absorption  of  the  temporary  teeth. 

Fig.  8  represents  the  mouth  of  a  girl  between  eight  and  nine 
years  of  age.  The  picture  shows  the  teeth  of  the  left  side  of  the 
upper  jaw  with  the  permanent  central  incisor  well  developed  and 
the  lateral  incisor  presenting  an  interesting  feature.  There  seems 
to  be  a  thickness  of  its  roots  about  one-sixteenth  of  an  inch  from 
its  apex,  and  also  an  apparent  constriction  of  the  root  canal  (L). 
The  crown  also  seems  to  be  misshapen,  but  this  is  due  to  a  slight 
torsion  or  rotation  of  its  root.  The  temporary  cuspid  (M)  is  still 
in  place  with  but  little  absorption  of  its  root.  Above  this  tooth 
and  in  front  of  it  can  be  seen  the  crown  of  the  permanent  cuspid 
with  its  root  partly  formed  and  with  a  wide  apical  opening  and  a 
large  root  canal.  Behind  the  crown  of  the  first  bicuspid  below  this 
tooth  is  the  crown  of  the  first  temporary  molar. 

Fig.  9  shows  the  mouth  of  a  child  ten  years  of  age.  The 
second  temporary  molar  is  still  in  place  and  the  second  bicuspid 
{N)  is  directly  above  it.  This  plate  shows  the  undeveloped  root 
of  the  first  bicuspid,  also  the  crown  of  the  upper  temporary  cuspid 
(0)  tilted  back,  and  the  permanent  cuspid  almost  erupted. 

Fig.  10  shows  the  right  side  of  the  upper  jaw  of  a  girl  between 
seven  and  eight  years  of  age.    The  central  incisor  is  well  developed 


DISEASES  OF  THE  HEAD  AND  SPINE.  123 

and  the  temporary  lateral  incisor  is  still  in  place,  not  absorbed 
but  deflected  forward  by  the  erupting  permanent  cuspid  (P) .  The 
temporary  cuspid  (Q)  shows  its  root  partly  absorbed.  The  first  and 
second  temporary  molars  have  not  been  lost,  but  their  roots  are 
completely  absorbed.  The  first  and  second  bicuspids  can  be  seen 
directly  above  them.  The  development  of  the  roots  of  these  teeth 
does  not  appear. 

Fig.  11  shows  that  with  the  exception  of  the  tooth  at  the 
extreme  left,  which  is  the  right  upper  central  incisor,  all  of  the 
other  areas  of  density  represent  the  temporary  teeth.  The  areas 
above  represent  the  permanent  teeth,  that  is,  the  right  upper 
cuspid  (R)  and  the  first  and  second  bicuspids  which  are  in  the 
process  of  eruption. 

SPINE 

The  spine  is  best  described  separately  from  the  rest  of  the 
skeleton,  as  its  position  behind  the  sternum  and  the  various  organs 
not  only  interferes  with  a  clear  picture  of  other  parts  but  also  is 
liable  to  affect  its  own  definition.  It  is,  however,  my  intention  to 
describe  the  spine  and  its  diseases  in  a  general  way  and  only  with 
the  purpose  of  indicating  what  especial  conditions  can  be  practically 
shown  by  the  Roentgen  method.  According  to  our  experience  in  the 
various  cUnics  of  the  Children's  Hospital,  where  a  very  large  num- 
ber of  Roentgenographs  are  taken  ever>'  year,  the  information 
obtained  by  the  clinical  examination  of  the  spine  rarely  compares 
favorably  with  the  condition  disclosed  by  the  Roentgen  ray.  At 
present,  owing  to  the  difficulty  of  the  technic,  it  is  not  possible  to 
take  satisfactory^  Roentgenographs  of  the  lateral  views  of  the  spine. 
Almost  without  exception  our  hospital  subjects  are  taken  with  the 
back  on  the  plate,  since  this  is  the  position  in  which  the  pictures  of 
the  vertebrae  are  least  interfered  with  by  those  of  other  parts  of 
the  body.     It  is  important  that  the  entire  vertebral  column  should 


124  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

in  each  case  be  looked  over  carefully,  for  in  this  way  most  valuable 
information  can  be  obtained  in  regard  to  practical  treatment.  What 
we  should  determine  in  abnormal  conditions  of  the  spine  is  the  dif- 
ferentiation of  abnormalities  which  have  occurred  before  birth 
during  the  process  of  development  from  post-natal  traumatism 
and  infection.  The  former  class  of  cases,  the  prenatal,  has  already 
been  described  in  Division  III,  Plate  41  (anomalous  atlas  and 
axis),  Plates  42,  43  and  44  (spina  bifida).  I  shall  not  attempt  to 
describe  the  traumatic  class  of  cases,  as  they  are  so  closely  con- 
nected with  the  work  of  the  orthopedist,  and  comprise  in  themselves 
such  a  wide  field  of  study,  that  they  would  require  a  special  treatise 
to  do  them  justice.  The  various  degrees  of  so-called  functional, 
better  designated  as  inorganic,  abnormalities  of  the  spine,  such  as 
lordosis,  kyphosis  and  scoliosis,  arising  from  postural  deformities, 
are  readily  diagnosticated  by  means  of  the  Roentgen  ray.  Although 
the  external  clinical  evidence  of  these  conditions  is  of  the  greatest 
value  in  the  hands  of  an  expert  in  this  branch  of  medicine,  yet  the 
readily  obtained  Roentgen  picture  is  so  valuable,  instructive,  and 
important,  especially  in  complicated  cases,  that  it  is  safer  to  make 
use  of  it,  if  for  no  other  reason  than  that  some  unsuspected  abnor- 
mality may  be  brought  to  hght.  It  is  worth  while,  therefore,  to 
become  familiar  with  the  normal  conditions  of  the  spine,  and  to 
study  its  position,  the  texture  of  the  vertebrae,  the  radiability  indi- 
cating breaking  down  of  one  or  more  bodies,  the  condition  of  the 
intervertebral  discs,  and  the  relation  of  the  transverse  processes  to 
the  hues  of  the  entire  column.  In  this  way  also  we  can  detect  vari- 
ous degrees  of  curvature  and  rotation  and  recognize  not  only  postural 
defects  but  actual  lesions  of  the  bone  and  cartilage.  Keeping  this 
idea  in  view  I  will  refer  you  to  Plate  23,  which  shows  the  normal 
spine  at  ten  years. 

It  cannot  be  too  strongly  emphasized  that  a  recognition  of 


DISEASES  OF  THE  HEAD  AND  SPINE.  125 

abnormal  conditions  of  the  spine,  as  shown  in  the  Roentgenograph  of 
the  vertebrae  and  cartilaginous  discs,  depends  upon  a  precise  knowl- 
edge of  the  various  details  shown  in  the  pictures  of  such  normal 
conditions.  The  finer  diagnoses  of  diseased  conditions  are  attained 
by  the  power  to  interpret  the  normal  conditions  in  their  various 
stages  of  development,  as  well  as  by  the  skilful  differentiation  of  the 
densities  where  they  are  interfered  with  by  the  thoracic  and  abdom- 
inal organs. 

The  diseases  which  can  be  diagnosticated  in  the  spines  of  chil- 
dren are  not  very  numerous.  The  various  degrees  of  thickening  and 
rigidity  of  the  vertebrse,  caused  by  hypertrophic  and  atrophic  con- 
ditions, are  as  uncertain  in  their  etiology  as  are  the  same  conditions 
in  the  joints.  They  are  indeed  so  rare  in  early  Ufe  that  they  should 
not  be  dwelt  upon  to  any  great  extent.  Rhachitic  conditions  not 
uncommonly  show  themselves  in  the  spine.  There  are  a  few  specific 
infections  which  attack  the  spine,  occasionally  an  osteomj^elitis,  but 
this  is  rare.  The  organism  which  plays  the  greatest  role  in  the 
spinal  infections  of  childhood  is  the  bacillus  of  tubercle.  The  result 
of  this  infection  in  its  chronic  form  is  what  is  usually,  though  not 
advisedly,  spoken  of  as  Pott's  disease. 

A  few  rules  in  connection  with  what  we  may  expect  to  see  and 
what  we  are  to  look  for  in  the  Roentgen  examination  of  the  spine 
may  be  of  value  to  the  student  and  to  the  general  practitioner.  Func- 
tional or  inorganic  lateral  curvature  is  characterized  by  a  single  or 
double  curve  of  comparatively  slight  degree  and  usually  to  the  left  in 
about  90  per  cent,  of  all  cases.  In  such  cases  the  left  shoulder  is 
higher  than  the  right.  There  is  usually  no  rotation  of  the  trans- 
verse processes  which  are  seen  equally  well  on  either  side  of  the 
spine.  There  are  also  transitional  cases  which  are  produced  by  such 
causes  as  congenital  absence  of  the  ribs,  causing  scoliosis.  Again  in 
this  set  of  cases  there  are  curvatures  resulting  from  operations  on  the 


126  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

thorax,  notably  for  empyema.  Plate  130,  Division  VI,  is  an  example 
of  this  condition.  In  structural  or  organic  curvatures  the  following 
conditions  may  be  looked  for:  single  curves,  representing  either 
kyphosis,  scoliosis,  or  loi'dosis;  and  compound  curves  consisting  of 
one  or  more  curves  in  different  parts  of  the  spinal  column  with  rota- 
tion in  the  opposite  direction.  There  are  also  to  be  noted  changes  in 
the  intervertebral  discs  and  in  the  bodies  of  the  vertebrae  showing 
disturbance  of  normal  structure  and  abnormal  radiability.  The 
pathologic  condition  may  be  a  periostitis,  osteitis  or  osteomyelitis, 
with  the  end  results  of  breaking  down  of  one  or  more  bodies  of  the 
vertebrae.  The  non-tubercular  infections  are  much  more  rare  than 
the  tubercular,  which  are  very  conmion,  and  of  the  tubercular 
class  the  chronic  form  is  more  common  than  the  acute.  Other  con- 
ditions, such  as  osteomalacia,  osteogenesis  imperfecta,  chondrodystro- 
phia  foetalis,  and  malignant  growths,  may  sometimes  also  be  present. 
Having  once  detected  and  located  the  part  of  the  spine  affected, 
note  should  be  made  of  the  amount  of  deformity  or  curves  of  the 
whole  spine,  the  number  of  vertebrae  diseased,  the  amount  of  bone 
involved,  and  the  condition  of  the  intervertebral  discs.  The  inter- 
vertebral discs  when  diseased  usually  show  atrophy  and  they  may 
seem  to  be  nearer  together  than  normal. 

Plate  100  shows  the  spine  of  a  colored  boy  six  years  of  age  with 
rhachitis.  The  rhachitic  process  is  in  this  instance  in  an  early  stage 
of  change  from  the  normal,  and  is  especially  seen  in  the  transverse 
processes  of  the  third  lumbar  vertebra,  which  are  slightly  increased 
in  size  and  show,  as  does  the  ilium,  a  coarse  arrangement  of  the 
structure  of  the  bone.  The  radiability  is  increased  throughout  the 
lumbar  vertebrae.  There  is  no  particular  disturbance  in  the  zone  of 
proliferation. 

The  non-tubercular  infections  of  the  spine,  although  rare,  yet 
must  be  recognized  and  separated   from  the  common  tubercidar 


DISEASES  OF  THE  HEAD  AND  SPINE.  127 

infections.  The  most  common  form  of  the  non-tubercular  a.ffections 
which  can  be  studied  by  the  Roentgen  ray  is  osteomyelitis.  An 
early  diagnosis  of  osteomyelitis  of  the  spine  is  difficult.  In  contra- 
distinction from  tubercular  there  is  a  more  localized  infection  of  one 
body  or  partial  destruction  of  the  vertebrae.  There  is  more  proUfer- 
ation  of  tissue  about  the  body  of  the  vertebra  and  usually  very  httle 
deviation  of  the  spine.  There  is  usually  the  history  of  an  acute 
infection. 

Plate  101  shows  the  lesions  of  osteomyelitis  of  the  spine  in  a 
girl  four  and  a  half  years  old.  There  is  a  destructive  process  with  an 
effort  at  reconstruction  of  the  second,  third,  and  part  of  the  fourth 
lumbar  vertebrae.  The  body  of  the  third  lumbar  vertebra  is  almost 
destroyed,  especially  on  the  right  side. 

Tuberculosis  of  the  spine  locates  itself  almost  exclusively  in  the 
bodies  of  the  vertebrae,  attacking  primarily  only  the  interior  of  the 
bodies  and  rarely  their  surface.  This  tubercular  osteitis,  when  it 
has  progressed  sufficiently,  causes  collapse  of  the  vertebral  columns. 
The  intervertebral  cartilage  is  also  often  destroyed  by  the  process, 
but  the  arches  of  the  vertebrae  are  only  in  rare  instances  affected. 
Abscesses  may  form  later  in  the  midst  of  the  broken-down  tubercular 
bodies  of  the  vertebrae  and  may  be  of  varying  size  after  they  have 
broken  through  into  the  surrounding  soft  parts.  Where  the  diseased 
condition  is  at  all  advanced  the  diagnosis  by  means  of  the  Roentgen 
ray  is  easily  made,  but  it  is  much  more  difficult  in  the  very  early  or 
hyperaemic  stage.  As  the  process  goes  on,  however,  a  larger  area  is 
involved  and  this  will  be  seen  in  the  bodies  of  the  vertebrae,  particu- 
larly in  the  spongy  portion,  as  an  area  more  or  less  definite  and 
showing  an  increase  of  radiability.  This  means  that  the  normal 
structure  of  the  bone  is  changed,  and  that  the  ray  passes  more  easily 
through  the  bone  in  this,  the  diseased  portion,  than  tlirough  the 
other  portions.    If  the  process  continues  the  area  of  disease  becomes 


128  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

larger,  destruction  of  the  bone  takes  place,  and  finally  cheesy  degen- 
eration of  its  centre  goes  on  with  still  greater  increase  of  radiability. 
Possibly  a  localized  abscess  of  the  bone  may  result.  This  too  may  be 
readily  detected  by  its  increased  density.  If  the  disease  progresses 
we  find  softening,  greater  density  of  one  or  more  bones,  and  a  crush- 
ing together  of  the  bodies.  At  this  time  in  the  history  of  the  case 
the  intervertebral  cartilage  has  disintegrated  and  disappears.  In 
regard  to  the  formation  of  an  abscess,  the  abscess  may  be  first 
external,  and  second,  internal,  as  a  mediastinal  abscess.  Almost 
every  case  of  tubercular  infection  of  the  spine  will  be  seen  to  have 
an  abscess.  This  condition  can  readily  be  differentiated  by  the  ray. 
To  be  interpreted  from  the  plate  are : 

1.  The  external  area  of  disease,  shown  in  the  plate  by  decreased 
radiability,  usually  limited  to  the  diseased  portions. 

2.  The  mediastinal  as  a  definite  area  of  increased  density 
ballooning  out  and  around  the  diseased  portion. 

Plate  102  shows  an  absorption  and  fusion  of  the  intervertebral 
cartilages  of  the  third  and  fourth  lumbar  vertebrae.  The  destruction 
of  a  part  of  the  left  ilium  is  seen  just  above  and  outside  of  the  acetab- 
ulum. The  third  and  fourth  vertebrae  give  evidence  of  necrosis, 
showing  more  destruction  on  the  right  side  than  on  the  left.  There 
is  an  e\'ident  necrosis  of  the  bone  of  the  ilium,  with  abscess  about 
the  left  hip-joint.  There  is  decreased  radiability  of  the  femur  on 
the  left  side. 

Plate  103  shows  a  tubercular  process  of  the  sacro-iliac  joint, 
causing  deformity  of  the  pelvic  line  of  the  left  side.  There  is  also  a 
marked  increase  in  the  radiability  of  the  ilium,  except  where  a  dark 
rim  denoting  the  boundary  of  the  destructive  process  shows  new 
bone  formation  and  consequent  decreased  radiability.  There  is 
more  or  less  destruction  of  the  sacrum  on  the  left  side,  and  marked 
deformity  of  the  pelvis  resulting  from  the  actual  destruction  of  the 


DISEASES  OF  THE  HEAD  AND  SPINE.  129 

sacro-iliac  joint.  There  is  also  an  atrophy  of  quality  of  the  acetab- 
ulum, as  well  as  of  the  whole  femur  on  the  left  side,  as  shown  by  the 
increased  radiability,  although  there  is  no  change  in  the  size  of  the 
shaft. 

Plate  104  shows  in  the  tenth  dorsal  vertebra  the  beginning  of  an 
absorption  and  a  destruction  with  fusion  of  the  body  with  the  ninth 
dorsal  vertebra.  At  about  this  point  thickening  of  the  tissue  and 
the  formation  of  an  abscess  are  apparent  in  the  Roentgenograph. 

Plate  105  is  that  of  a  child  four  years  old  and  shows  tubercular 
lesions  of  the  spine.  There  is  an  absorption  of  the  tenth,  eleventh, 
and  twelfth  dorsal  intervertebral  cartilages  to  the  right,  with  an 
apparent  fusion  of  these  bodies.  At  the  tenth  dorsal  vertebra  is 
seen  the  beginning  of  an  absorption  and  a  destruction  with  fusion  of 
the  body  with  the  ninth  dorsal  vertebra  on  the  left  side.  At  this 
point  also  there  is  either  breaking  down  of  the  neighboring  tissues 
or  the  formation  of  an  abscess,  as  is  seen  to  the  right  in  the  Roent- 
genograph. 

Plate  106  gives  a  lateral  view  of  the  same  subject,  and  shows 
that  there  is  complete  absorption  of  the  twelfth  dorsal  and  partial 
destruction  of  the  eleventh  dorsal  vertebrae.  It  is  well  to  compare 
this  process,  which  is  clean  cut,  with  that  shown  in  osteomyelitis, 
Plate  101.  It  will  be  noticed  that  the  abdomen  is  rather  prominent 
and  that  lordosis  is  present. 


PLATE  90. 
FRACTURE  OF  SKULL. 

Boy,  age  13  years.    (Reduced  39%.) 

A.  Frontal  sinus. 

B.  Orbit. 

C.  Sphenoidal  sinus. 

D.  Region  of  antrum. 

E.  F.  A  fracture  of  the  base  of  the  skull. 


Plate  90 


PI.ATK  91. 

ETHMOIDITIS. 

Age  3  years     (Reduced  12%.) 

A.  Frontal  sinus. 

B.  Second  lower  temporary  molar. 

C.  Central  and  lateral  upper  incisors  (not  well  defined). 

D.  Permanent  upper  eusijid. 

E.  Permanent  second  upper  bicuspid. 

F.  First  permanent  upper  molar. 

G.  First  permanent  lower  molar. 
H.  Inflammatorj'  area  (ethmoid). 

/.  Orbit. 

The  increased  density  shows  the  process  of   inflammation 
in  the  ethmoid  bone,  frontal  sinus,  and  antrum. 


Tlatk  {>1 


PLATl';  92. 
OSTEOMYELITIS  OE  LOWER  JAW. 

Colored  boy,  age  12  years.    (Life  size,  i 

A.  Frontal  sinus. 

B.  Ethmoidal  cells. 

C.  Floor  of  the  orbit. 

D.  Antrum. 

E.  Sphenoidal  .'^inus. 

F.  Left  permanent  upper  central  incisor. 

G.  Left  permanent  upper  lateral  incisor. 
H.  Left  upper  temporary  cuspid. 

/.  Permanent  upper  cuspid. 
.7.  First  upper  bicuspid  (misplaced). 
K.  Second  U])per  bicuspid.      (Turned  one  qiiarter  around  and 

pointing  backward.) 
L.   First  and  second  upper  temjiorary  molars. 
.1/.  Second  upper  permanent  molar. 

A  tooth,  a  second  lower  molar,  was  found  at  a  second 
operation  in  the  soft  tissues  of  the  lower  jaw,  the  sequestrum 
havinjr  been  removed  at  the  first  oi)cration. 


Platp:  92 


ri.ATK  03. 
ANOMALOUS  BICUSPIDS— I.KI'T  SIDK  OF  HEAD. 

Boy.  age  13  yeans.     (Life  size.)     (Same  .'-ubject  a^  IMate  94.) 

A.  Frontal  sinus. 

B.  Orbit. 

C.  Sphenoidal  sinii.s. 

D.  Antrum. 

E.  First  and  second  upper  temporary  molars. 

F.  Third  permanent  up|)er  molar. 

(The  cusjjs  of  this  tooth  are  just  beginning  to  show  calci- 
fication). 

G.  Crypt  of  tliird  lower  molar. 

H.  First  lower  bicusi)id  (unerupted). 
/.  Second  lower  bicuspid  (unerupted). 


Plate  93 


PT.ATK  91. 

ANOMALOUS  LOW  EU  BICUSPID— RIGHT  SIDE  OF  HE.\D. 

Boy,  age  13  years.    (Life  size.)    (Same  subject  as  Plate  93.) 

.4.  Frontal  sinus. 

B.  Orbit. 

C.  Sph(^noidal  sinus. 

D.  Antrum. 

/.  Unoruptcd  second  lower  bicuspid. 


Platk  94 


PLATE  95. 
UXERI'PTED  PERMAXEXT  TEETH     HICIIT  SIDE  OF  IlKAI). 

huy,  age  S  year>.     U-ife  size.) 

.1.   Frautul  sinu.s. 

B.  Orbit. 

C.  Sphenoidal  sinus. 

D.  I'ltlimoiilal  cells. 
E  and  F.  Antrum. 

a.   lU^ht  central  ujJiier  incisor.      (I'lKM'upted  root  only  jiartly 

calcified.) 
H.  Right  permanent  upper  lateral  incisor. 
/.  Permanent  upper  cuspid. 
/.  First  upper  temporary  molar. 
K.  Second  up])ei-  bicuspid. 
L.  Secontl    temporary    upper    molar.      (Partly    absorbed,    and 

crown  destroyed  by  caries.) 
M.  Second  permanent  upper  molar. 
.V.  Second  permanent  lower  molar. 
0.  Crown  of  the  second  lowc'i'  bieusiiid  in  its  crypt. 
P.  Crown  of  the  first  lower  l)icuspid. 
Q.  Teeth  on  left  side  of  the  jaw. 


Platk  95 


PLATK  96. 

SUPKRXUMEHAUV  TOOTH— LEFT  SIOK  OF  HEAD. 

H<'>'.  aiie  ITt  years.    (Life  size.) 

A .  I'"n)ntal  .'^iiuis. 

li.  ]<:thinoidal  colls. 

('.  Sphenoidal  sinus. 

/).  Roof  of  orbit. 

E.  Antrum. 

F.  Supernumerary  tooth  above  upper  lateral  incisor,  in  palatal 

aspect. 
a.  Third  upi)er  niohir  in  its  crypt. 
//.   Third  lower  molar  in  its  crypt. 


Plate  96 


PLATE  97. 

SUPERNUMERARY  TOOTH— RIGHT  SIDE  OF  HEAD. 

Girl,  age  14  yean«.    (Life  size.)    (Same  subject  as  Plate  98.) 

.1.   Frontal  sinu.-;. 

B.  Ethmoidal  cells. 

C.  Orbit. 

E.  .\ntrum. 

F.  Glenoid  fo.-^sa. 

G.  Condyle  of  inferior  maxillary  bone. 
H.  Right  u]jper  cuspid. 

/.   A  supornumcrary  tooth  showinfi;  the  givatcr  density  caused 

by  the  overlapping  of  the  right  upper  central  incisor. 
J.  Right  upper  lateral  incisor. 


Plate  97 


I'LATl':  !)S. 
SUPERNUMERAliY  TOOTH— LEFT  SIDE  OF  HEAD. 

(lirl.  age  14  years.     (Life  .<ize.)     (Same  subject  us  riate  97.) 

A.  Frontal  sinus. 

B.  Ethmoidal  cells. 

C.  Oibit. 

D.  Sphenoidal  sinus. 

E.  Antrum. 

F.  Left  upper  cuspid. 

a.  Supernumerary  tooth. 
H.   Left  upper  lateral  incisor. 


Platk  98 


F_ 


PLATE  99. 

VARIOUS  ANOMALOUS  COXDITIOXS  COXNECTED  WITH  THE 

TEETH. 

Fig.  1.  Child,  .\ge  14  Ye.vrs. 

A.  Area  whcro  the  missing  second  bicuspid  should  be. 
Fic:.  2.  Child,  Acie  14  Years. 

Opposite   side   of   and   corrospomling  part   of  jaw   to   that 
shown   in   Fig.   1.     The   first    permanent   molar  ai)pears  to   the 
right  in  this  Fig. 
Fig.  3.  Child,  Age  1.3  Yeaks. 

Absence  of  the  second  l)icus])id.     The  temporary  molar  is 
present  with  no  absorption  of  its  root. 
Fig.  4.— 

B.  Left  upper  ]jermanent  cuspid. 

C.  Left  upper  iK'rmanent  lateral  incisor. 

D.  Left   upper   supciiuimerary   or   temporary    lateral 

incisor. 

E.  Left  upper  temporary  cuspid. 

F.  Left  upper  jiermanent  first  bicuspid. 
Fig.  .5. — 

Shows  superior  cuspids  direclU'  behind  the  central  incisors. 

Fig.  0.  Girl,  Age  9  Ye.a.rs. 

G.  Tip  of  the  right  upper  permanent  cuspid. 
H.    Left  upper  permanent  cuspid. 

/.    Left  upper  temporary  cus])iil. 
./.   Left  upi)er  first  bicuspid. 
K.   Left  upper  second  bicuspid. 

Fig.  7.  Child,  Age  S  Years. 

Shows  the  absorption  of  the  roots  of  the  tetnporary  cusjjid 
and  the  first  and  second  temporary  molars. 
These  teeth  are  about  to  be  exfoliateil. 

The   permanent   teeth    are   directly   al)ove   and   are   in  the 
process  of  eruption. 
Fig.  S.  Girl,  Between  S  and  D  Years  of  Age. 

L.   Left  upper  ]iermanent  lateral  incisor. 

.1/.   Left  upper  temporary  cuspid. 
Fic    0.  Child,  .Vge  10  Years. 

-V.   Right  upper  second  liiciispid. 

0.  Right  upper  temporary  cuspid. 
Fig.  10.  Girl,  Between  7  and  8  Years  of  .Vge. 

P.   Right  upper  permanent  cuspid. 

Q.  Right  upper  temporary  cuspid. 
Fig.  11.  Child.  .\ge  10  Years. 

R.   Right  upper  cuspid. 


FIG.  I. 


FIG. 2. 


Plate  99 

FIG.  3. 


FIG.  4. 


FIG.  6. 


FIG.  5. 


FIG.  7. 


FIG.  9. 


PLATE   100. 
RIIACIIITIS  ()|-  SI'IXIO. 

Co'.ore'l  boy,  age  G  years.     (lieduced  2S1%.) 

The  Ixjiics  sliow  ;i  coarser  str\ictiiic,  t'spocially  those  of  the 
vertebra',  than  •\\h)u1(1  he  noi'iiial  for  a  ehild  of  tliis  aiic 
The  arrow  points  towards  an  area  of  rhachitis. 


Plate  100 


f 
I 

f 
I 
t 


• 


f 


PLATK   101. 
OSTEUMYKLITIS  OF  \KKTEBR.E. 

Girl,  age  4\  year?.     (Keilueed  21^,.) 

The  ai'i'dw  [xiiiits  t()\var(ls  tlic  thinl  liiiiiliai'  \ritrl)i-a,  which 
is  hirger  than  the  olhcr  \erteljra'.  and  shows  great  (Usoiguniza- 
tion  in  the  lower  pait  of  tlie  body  and  evidence  of  new  fornuition 
of  hone  in  the  region  of  the  transverse  process. 


Pl,ate  101 


I'l.ATi:  loj. 
TUBERCULOSIS  OF  Till:  si'iNi;.  II, MM.  \xi)  i.i;ft  hip. 

(UeiluceJ  211%.) 

.-1.   Points    toward    the    tulici'cuhu-    lesions    of    tiic    tliird    ami 
fourth  lumbar  vertebra'. 

B.  Designates  the  same  process  in  llic  iliiun. 

C.  Indicates  an  abscess  of  the  left  hip.  the  soft  tissues  being 

ffreatlv  involved. 


PI.ATE  102 


I'l  \TF  in:'. 

TrBKRClLUSIri  OF  TIIK  II. UM. 
(Reduced  aSJTc.l 

Tlic   arrow   points   towards  a   tubercular  comlitioii   of  the 
iliosacral  svnchuiidrosis. 


Plate  103 


i 


PLATI-:    11)1. 

TUBERCULAR  AMSCKSS  OK  THi;  SPIXK. 

Tlir   arrows  ])oiiit    towards   the   vertebra'   affected     luunely, 
the  ninth  and  tenth  dorsal. 


PXATK  104 


PLATE   lOo. 
TUBERCULOSIS  OF  THE  SPINE. 

Chil.l,  au'i-  4  ypars.     (Reduced  31%.)     (Same  subject  as  I>late  lOii.) 

10.   11   and   12  indiciito  tho  breaking  down  of  the  interver- 
tebral cartilages  and  the  fusion  of  tlii'  bodies. 


PliATE  105 


% 


PLATE  li)(i. 

(Reduced  32%.) 

The  samo  case  as  Plato  10")  but  presenting  a  lateral  view 
of  the  spine. 

The  arrow  ])()ints  toward   an  area  of  comijlcte  absorption 
of  the  bodies  of  the  eleventh  and  twelfth  vertebra-. 
B.  The  anterior  aspeet  of  the  body. 


PliATE  ]()(; 


Division  VI 

THE  BRONCHIAL  NODES— BRONCHI— LUNGS— PLEURA— HEART- 
PERICARDIUM— ANEURISM 

Among  the  more  difficult  interpretations  which  we  have  to 
make  in  reading  a  Roentgenograph  are  those  connected  with  intra- 
thoracic conditions.  It  is  very  necessary  that  we  should  first 
carefully  study  the  normal  conditions  as  seen  in  Plates  8  and  19, 
before  attempting  to  interpret  the  abnormal.  This  is  difficult  since 
there  is  no  one  set  of  pictures  which  we  can  memorize  as  normal, 
and  since  the  entire  interpretation  of  an  individual  plate  depends 
upon  the  comparison  of  the  different  densities  which  happen  to  ap- 
pear on  that  individual  plate.  These  densities  differ  very  much, 
whether  of  lung,  heart,  or  fiver.  In  a  Roentgenograph  of  a  normal 
thorax  we  can  see  the  very  slight  density  of  the  lung  with  its  great 
radiabifity,  the  sfightly  greater  densities  of  the  bronchial  nodes,  the 
much  greater  densities  of  the  heart  and  spine,  and  the  still  greater 
densities  of  the  heart  and  spine  where  they  overlap  each  other  and 
show  very  sUght  radiability.  To  be  noted  carefuUy  as  an  aid  in 
detecting  abnormal  conditions  are  the  outlines  of  the  heart  and  its 
angle  with  the  liver,  especially  on  the  right  side.  This  angle  is  very 
important  where  there  is  a  question  between  a  pericardial  effusion 
and  an  enlarged  heart.  To  obtain  the  best  results  in  Roentgeno- 
graphs of  the  thoracic  organs  certain  details  connected  with  the 
technic  are  important.    Among  these  is  the  time  of  the  exposure. 

Dr.  Percy  Brown  has  shown  for  me  the  great  advantage  of  a 
short  over  a  long  exposure  in  Plates  107  and  108.  Plate  107  shows 
an  exposure  of  six  seconds  with  the  child  breathing  normally. 
Plate  108  shows  the  thorax  of  the  same  child  taken  with  the 
respiration  arrested  and  with  an  exposure  of  one  second.    The  latter 

131 


132  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

picture  is  seen   to  portray  the  lungs  and  heart  with  far  greater 
accuracy  than  the  former. 

The  immobility  of  the  parts  taken  explains  these  results,  and 
naturally  the  immobility  is  greater  the  more  the  respiration  is 
arrested. 

BRONCHIAL  NODES 

The  broncliial  nodes  under  normal  conditions  are  often  not  seen 
in  the  plate,  but  where  the  movement  of  the  lung  is  at  all  restricted, 
as  in  disease,  and  often  when  the  child  is  breathing  verj^  quietly 
and  the  expansion  for  half  a  minute  is  slight,  the  nodes  when  en- 
larged can  be  distinguished.  They  are  seen  especially  to  the  right 
quite  close  to  the  border  of  the  sternum,  where  they  are  not  com- 
pUcated  by  the  picture  of  the  heart.  \Vhen  enlarged  they  become 
quite  distinct. 

Plate  109  shows  the  picture  of  a  girl  twelve  years  old.  The 
lungs,  pleura,  pericardium  and  heart  are  normal.  On  the  right  side 
of  the  thorax  just  outside  the  boundaries  of  the  heart  and  extending 
in  a  narrow  area  from  the  top  to  the  bottom  of  the  thorax  are  a 
number  of  separate  dark  areas  in  each  of  the  interspaces.  They 
evidently  represent  areas  of  enlarged  bronchial  nodes,  and  are  seen 
at  times  in  a  normal  thorax. 

Plate  110  shows  a  transposition  of  the  heart  and  liver  in  a  child. 
On  the  left  side  of  the  thorax  there  will  be  seen  to  be  far  less  dark 
areas  than  on  the  right,  but  that  whatever  areas  of  lessened  radia- 
bility  there  are  on  the  left  from  the  second  to  the  seventh  ribs  are 
very  marked.  These  dark  areas  show  the  characteristic  appear- 
ances of  an  advanced  tuberculosis  of  the  bronchial  nodes.  The  en- 
tire area  to  the  left  of  the  heart  is  mottled  and  hea\y  in  outhne, 
showing  that  the  bronchial  nodes  are  involved,  but  to  a  lesser 
degree  than  on  the  right  side.  The  lower  part  of  the  lung  on 
the  left  is  seemingly  normal;  on  the  right  side  the  density  is  very 


BRONCHI— LUNGS.  133 

great  throughout,  but  is  greatest  from  the  fifth  down  to  the  tenth 
interspace.  In  this  region  and  between  the  sixth  and  eighth 
interspaces  just  to  the  left  of  the  spine  can  be  seen  the  density 
of  the  heart.  The  cause  of  the  general  intensely  increased  density 
on  the  right  is  possibly  thickened  pleura,  and  except  at  the  apex 
practically  no  lung  substance  can  be  seen.  The  dark  area  at  the 
lower  point  of  the  thorax  on  the  left  is  the  picture  of  the  transposed 

hver 

BRONCHI 

WTien  expansion  of  the  lung  is  restricted  by  consolidation, 
or  when  the  breathing  is  unusually  quiet,  the  bronchi  can  be  dis- 
tinguished quite  readily  as  faint  areas  of  increased  density  radi- 
ating from  the  base  of  the  lung.  This  is  seen  in  Plate  19,  Di\'ision 
I.  If  this  appearance  were  produced  by  a  mediastinal  abscess  the 
condition  would  be  represented  by  a  balloon-shaped  area  on  either 
side  of  the  mediastinal  line  instead  of  the  radiating  oranch-Uke 
irregularities  seen  in  the  picture.  The  movements  of  the  bronchi 
are  usually  xevj  free  on  account  of  their  being  surrounded  by  normal 
elastic  tissue,  and  therefore  we  are  more  apt  to  see  them  when 
there  is  a  consolidation  of  the  lung,  with  its  consequent  restriction 
of  motion. 

LUNGS 

Atelectasis. — There  is  no  especial  diflference  which  can  at  present 
be  detected  between  the  decreased  radiability  of  an  atelectasis  and 
that  of  a  pulmonary  consolidation.  When  at  birth,  in  connection 
with  sjTnptoms  of  cyanosis,  rapid  irregular  breathing,  coldness  of 
the  extremities,  and  a  subnormal  temperature,  we  find  parts  of  the 
lung-tissue  showing  a  decidedly  decreased  radiability,  we  can  with 
considerable  assurance  make  the  diagnosis  of  atelectasis.  At  a  later 
period  also  as  a  sequel  to  pertussis  an  atelectasis  may  occur  and  be 
detected,     ^^^len  this  condition  is  seen,  the  differential  diagnosis 


134  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

from  the  pictures  resulting  from  infectious  processes  in  the  kmgs  is 
made  by  the  absence  of  fever,  and,  if  the  child  is  old  enough  to  ex- 
pectorate, by  the  absence  of  organisms  in  the  sputa.  In  saying  this 
we  simply  acknowledge  our  lack  of  skill  in  the  interpretation,  as  a 
different  picture  is  evidently  before  us,  the  atomic  weight  being 
different  in  the  two  conditions,  and  the  radiability  therefore  being 
greater  in  atelectasis  than  in  consolidation.  When  in  the  future 
the  Roentgen  apparatus  has  been  perfected  and  the  eye  is  more 
educated,  we  shall  be  able  to  accomplish  far  more  than  is  now 
possible  by  means  of  our  present  art. 

Plate  134  represents  the  condition  just  described  as  collapse  of 
the  alveoli  of  the  lung. 

The  pictures  which  show  abnormal  conditions  in  the  lungs  vary 
according  to  the  extent  of  the  areas  affected.  Thus,  when  a  whole 
lobe  is  involved,  as  in  lobar  pneumonia,  a  continuous  broad  tract 
of  lessened  radiability  discloses  such  a  condition,  while  smaller, 
irregularly  distributed  areas,  usually  bilateral,  point  towards  a 
bronchopneumonia.  Again,  still  smaller  scattered  areas  over  the 
whole  lung  lead  us  to  suspect  miliary  tuberculosis.  We  must, 
however,  merely  consider  these  Roentgen  pictures  as  suggestive 
rather  than  diagnostic,  and  only  confirmatory  of  other  signs,  both 
rational  and  physical.  In  certain  cases,  especially  in  infants  and 
in  young  children,  where  the  physical  signs  from  auscultation  and 
percussion  fail  to  detect  a  consolidation  of  the  lung-tissue,  the 
Roentgenograph  shows  a  density  which  reveals  the  cause  of  the 
respiratory  and  constitutional  symptoms  corresponding  to  a  con- 
solidation of  the  lung-tissue,  and  gives  a  means  by  which  we  can 
eliminate  the  presence  of  a  foreign  body  or  a  mediastinal  abscess.  A 
mediastinal  abscess  is  rare  in  early  life  except  in  connection  with 
tuberculosis  of  the  spine  (Plate  104),  where  it  can  be  detected  by  a 
picture  in  connection  with  the  Roentgen  examination  of  the  spine. 


LUNGS.  135 

Plate  111  shows  the  homogeneous  area  of  a  lobar  pneumonia 
of  the  left  upper  lobe  in  a  girl  three  years  old.  This  picture  gives 
the  characteristic  appearance  of  an  involvement  of  a  whole  lobe. 
The  outline  of  the  scapula  can  still  be  seen.  The  remainder  of  the 
lung  and  the  density  of  the  heart  are  normal. 

Plate  112  shows  a  lobar  pneumonia  in  a  boy  twelve  years  old. 
The  process  is  seen  to  involve  the  right  middle  lobe  and  is  plainly 
seen  in  the  third,  fourth,  fifth,  sixth,  and  seventh  interspaces.  A 
consolidation  on  the  left  is  also  seen  at  the  base  of  the  lung  from  the 
fifth  interspace  down.  The  outline  of  the  heart  is  rather  indistinct, 
but  the  cardiohepatic  angle  can  still  be  distinguished.  The  upper 
and  lower  lobes  on  the  right  and  the  upper  lobe  on  the  left  seem  to 
be  normal. 

Plate  113  shows  a  lobar  pneumonia  of  both  lower  lobes  behind 
in  a  child  ten  years  old.  The  right  lower  base  shows  much  decreased 
radiability  but  the  cardiohepatic  angle  is  evident.  The  process 
seems  to  involve  the  entire  lower  lobe  on  the  right.  On  the  left  a 
similar  process  in  the  lower  lobe  makes  the  outUne  of  the  heart  rather 
indistinct.  The  upper  lobes  are  practically  normal,  and  on  both  sides 
show  the  faint  pictures  of  the  bronchi,  especially  at  the  right  apex. 

Plate  114  shows  the  density  of  what  from  the  chnical  history 
was  a  case  of  unresolved  pneumonia  in  a  girl  four  years  old.  The 
pneumonic  process  is  shown  in  the  upper  part  of  the  right  lung. 
There  is  a  dorsal  curvature  from  position  shown  in  the  plate. 

Plate  115  shows  the  thorax  of  a  girl  twenty-seven  months 
old,  where  the  clinical  diagnosis  of  a  MongoUan  idiot  was  made. 
The  history  of  this  case  has  already  been  described  in  Division 
III,  Plate  65,  showing  the  hand  and  knee.  Wlien  the  child  was 
first  seen  the  clinical  examination  showed  that  it  had  a  con- 
solidation of  the  upper  part  of  the  right  lung.  The  Roentgeno- 
graph showed   complete   consolidation   of   the  upper  lobe.     Four 


136  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

weeks  later  another  Roentgenograph  was  taken  and  showed,  in  the 
middle  of  the  dark  area  representing  the  solidification,  a  round, 
clearly  defined  area  with  increased  radiability.  This  is  seen  in 
Plate  116.  The  tubercuUn  test  in  this  case  was  negative,  and  the 
question  was  whether  we  were  dealing  with  a  cavity  or  with  an  area 
of  the  decreasing  consolidation  of  a  resolution  in  a  pneumonic  area. 
The  clinical  signs  were  those  of  resolution.  A  Roentgenograph 
taken  still  later,  Plate  117,  showed  that  the  light  area  was  increasing. 

I  was  unable  to  get  a  later  Roentgenograph  of  the  case,  but 
I  was  notified  that  the  temperature  was  normal  and  that  the 
child  was  improving.  A  series  of  Roentgenographs  of  a  case  of  this 
kind  would  be  exceedingly  valuable  for  learning  to  determine  whether 
we  are  dealing  with  a  cavity  or  with  an  area  of  resolution.  Sufficient 
work  in  this  direction  has  not  yet  been  done  to  justify  us  in  any 
further  conclusions  regarding  the  case  at  this  stage.  Two  months 
later  the  child  was  reported  to  have  had  a  hemorrhage  seemingly 
from  the  lung  and  to  have  died  suddenly  (no  autopsy). 

Plate  118  shows  the  Roentgenograph  of  a  child  four  years  old. 
The  coarse  mottled  appearance  throughout  both  lungs  shows  gen- 
eral infiltration,  and  the  definite  areas  of  decreased  radiability  are 
what  would  be  expected  from  a  case  of  bilateral  bronchopneumonia. 
To  be  noted  is  the  still  ununited  upper  epiphysis  of  the  humerus, 
which  is  supposed  to  join  at  about  five  years. 

Plate  119  shows  a  pneumonia  of  the  right  lung  produced  by 
a  china  doll's  arm  which  was  inspirated  by  a  girl  four  years 
old.  The  progress  of  the  case  is  seen  in  Plates  148,  149,  and  150, 
Division  VIII. 

Plate  120  shows  the  lesions  of  an  acute  miliary  tuberculosis  in 
the  lungs  of  a  child  ten  years  old. 

Plate  121  shows  the  early  signs  of  tuberculosis  of  the  lungs 
which  were  not  detected  by  the  clinical  examination  until  some  time 


LUNGS— PLEURA.  137 

after  the  tuberculin  test  had  shown  the  presence  of  tubercle  bacilli. 
The  Roentgenograph,  on  the  other  hand,  at  once  showed  that  the 
case  was  one  of  miliary  tuberculosis. 

Plate  122  shows  the  lesions  in  the  right  lung  of  a  child  twelve 
years  old.  There  is  an  area  of  calcification  about  one  inch  in  diam- 
eter. There  are  also  multiple  areas  of  calcified  material,  showing 
the  remains  of  an  old  tubercular  caseous  area  with  an  active  process 
around  it. 

Plate  123  shows  the  Roentgenograph  of  a  girl  three  years  old. 
This  picture  presents  the  lesions  of  emphysema,  gangrene,  and 
tuberculosis.  The  left  lung  shows  the  emphysematous  condition 
expressed  by  extreme  radiability,  as  compared  with  the  picture  of 
the  right  lung.  At  the  base  of  the  left  lung  a  general  infiltration 
has  taken  place  and  is  represented  in  the  plate  by  a  mottled  appear- 
ance due  to  a  miUar}'  tubercular  lesion.  The  autopsy  proved  that  the 
lung  on  the  left  side  was  completely  disorganized  and  that  the  base 
was  riddled  with  miliary  tubercles.  There  was  also  a  complete 
gangrenous  condition  of  the  left  lung.     The  right  lung  was  normal. 

Plate  124  shows  acute  miUary  tuberculosis  of  both  lungs  in  a 
girl  twelve  years  old. 

Plate  125  shows  a  case  of  hydropneumothorax  in  a  boy  seven 
years  old,  the  picture  being  taken  in  the  upright  position.  Plate 
126  shows  the  same  boy  taken  when  lying  down. 

Plate  127  shows  the  condition  of  pneumothorax  in  the  same 
boy,  who  one  j-ear  previously  had  had  an  attack  of  hydro- 
pneumothorax. 

PLEURA 

Plate  128  shows  thickened  pleura  over  the  left  side  of  the  chest 
in  a  boy  six  years  old.  The  left  side  of  the  thorax  will  be  seen  to  be 
of  uniform  density,  except  for  a  small  area  in  the  fifth  interspace 
just  beyond  the  border  of  the  heart.    Thoracentesis  failed  to  detect 


138  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

any  fliiitl,  and  as  the  density  did  not  change  with  change  of  position, 
the  provisional  diagnosis  of  a  thickened  pleura  was  made.  The  lung 
on  the  right  side  appeared  to  be  emphysematous,  the  emphysema 
being  partly  caused  by  the  forced  compensatory  action  of  the  lung. 

It  must  be  remembered  that  in  all  these  Roentgenographs  of  the 
lungs  the  cases  have  been  carefully  examined  clinically  and  that  the 
interpretation  of  the  plate  must  be  much  influenced  by  the  clinical 
examination.  In  the  pneumonic  cases  where  they  were  at  all  ob- 
scure, not  only  was  the  exploratorj'  needle  used  to  support  the 
diagnosis,  but  the  tuberculin  test  was  given  in  those  cases  where  the 
resolution  was  prolonged;  that  is,  the  Roentgen  examination  was 
in  all  cases  additional  and  confirmatory  to  other  methods  of  exam- 
ination, and  often  proved  to  be  the  most  valuable. 

Plate  129  shows  an  effusion  into  the  left  pleura  of  a  child 
eight  years  old.  There  is  a  uniform  radiability  over  the  entire  left 
lung,  which  was  found  to  change  as  the  position  of  the  child  was 
changed.  It  is  to  be  noticed  that  where  the  fluid  was  greatest  in 
amount,  as  in  the  middle  of  the  involved  area,  the  density  was 
greatest,  while  on  the  edges  it  was  less  and  showed  greater  radia- 
bility. The  heart  was  slightly  displaced  to  the  right,  and  the  right 
lung  showed  slight  compensating  emphysema.  The  bronchi  are 
also  seen  on  either  side  of  the  sternum.  The  diagnosis  was  con- 
firmed by  an  exploratory  thoracentesis. 

Plate  130  shows  a  collapsed  condition  of  the  upper  ribs  on  the 
right  side  in  a  girl  six  years  old,  resulting  from  an  effusion,  probably 
an  empyema.  The  heart  is  drawn  to  the  right  and  held  there  by 
adhesions.  There  is  still  either  some  fluid  at  the  right  base  or  a 
greatly  thickened  pleura.  There  is  a  compensatory  emphysema  of 
the  left  lung. 

Plate  131  shows  an  encapsulated  empyema  verified  by  an 
operation  on  the  right  side  at  the  lower  base  in  a  boy  ten  years  old. 


HEART— PERICARDIUM.  139 

HEART 

Plate  132  shows  an  extreme  enlargement  of  the  heart  in  a 
child  ten  years  old,  filling  almost  the  entire  anterior  area  of  the 
thorax.  The  lung  on  the  right  side  shows  compression.  The  cardi- 
ohepatic  angle  is  seen  to  be  intact,  and  is  extremely  valuable  in 
making  the  differential  diagnosis  from  pericardial  effusion,  which  in 
this  case  it  closely  simulated,  since  the  encroachment  of  the  dull 
area  in  the  fifth  right  interspace  was  much  greater  than  usual. 
This  similarity  of  physical  signs  was  accompanied  by  a  similarity  of 
rational  signs,  as  the  extreme  dilatation  and  weakening  of  the  heart 
prevented  almost  entirely  the  cardiac  impulse  from  being  felt  and 
there  was  no  audible  murmur.  There  were  orthopncea,  cyanosis, 
a  weak  fluttering  pulse,  and  a  picture  as  much  of  pericardial  effu- 
sion as  of  enlarged  heart,  confirmatory  paracentesis  being  con- 
sidered seriously,  when  the  ray  settled  the  question  by  showing 
clearly  the  cardiohepatic  angle,  and  the  consequent  contraindica- 
tion for  paracentesis. 

PERICARDIUM 

Plate  133,  a  child  twelve  years  old,  is  an  instance  of  what  has 
just  been  stated  in  speaking  of  Plate  132.  This  picture  shows  a 
typical  case  of  a  heart  enlarged  considerably  on  both  sides,  but 
encroaching  but  little  on  the  fifth  right  interspace,  thus  following 
the  clinical  rule  as  to  the  usual  presence  of  resonance  in  that  space 
in  an  enlarged  heart.  Around  the  heart  is  seen  the  greater  radiabiUty 
of  the  effusion,  with  its  p>Tamidal  outline  below  and  at  the  sides 
and  extending  over  the  great  vessels  at  the  base  of  the  heart,  being 
indeed  the  typical  outhne  of  a  pericardial  effusion,  namely  a  half 
circle  with  its  greater  radius  to  the  left. 

So  far  as  I  know  this  is  one  of  the  first  cases  where  a  large  peri- 
cardial effusion  being  present,  and  the  rational  symptoms  of  peri- 
cardial effusion  and  of  enlarged  heart  being  similar,  it  was  possible 
not  only  to  diagnosticate  the  effusion  by  the  Roentgen  method, 


140  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

but  to  prove  also  that  the  heart  was  enlarged.  This  was  accom- 
plished by  recognizing  the  difference  of  radiability  between  the 
heart  itself  and  the  pericardial  effusion.  The  Roentgen  examina- 
tion was  made  in  the  upright  position  and  the  cardiohepatic  angle 
as  seen  in  the  plate  was  obliterated. 

Plate  134  is  a  case  of  pericardial  effusion  in  a  child  twelve 
years  of  age,  where  the  outline  of  the  heart  shows  it  to  be  enlarged. 
The  cardiohepatic  angle  is  obliterated  by  the  pericardial  effusion. 
The  lung  shows  compression  of  the  pulmonary  tissue,  correspond- 
ing to  what  would  be  expected  in  the  Roentgenographic  picture 
produced  by  an  atelectasis. 

Plate  135  is  the  picture  of  a  pericardial  effusion  in  a  child. 
The  decreased  radiability  extends  from  the  sixth  rib  to  the  base  on 
the  right,  and  from  the  fourth  interspace  to  the  base  on  the  left. 
The  cardiohepatic  angle  was  obliterated,  as  is  seen  on  the  right. 
The  whole  lung  shows  compression  and  lessened  radiability.  The 
darker  area  in  the  centre  of  the  large  and  lighter  area  shows  indis- 
tinctly the  heart  itself,  which  does  not  seem  to  be  enlarged.  The 
Roentgen  ray  gives  us  the  only  known  method  by  which  in  most 
cases  of  large  pericardial  effusion  a  determination  can  be  made  as 
to  whether  the  heart  is  of  normal  or  abnormal  size,  suspended  as 
it  is  in  the  pericardial  sac.  This  is  accomplished  by  a  close  obser- 
vation of  the  dark  central  outlines  of  the  heart,  which  we  are  thus 
able  to  distinguish  from  the  surrounding  outline  of  the  effusion  and 
the  still  lighter  area  of  the  compressed  lung. 

ANEURISM 

Plate  136  is  the  Roentgenograph  of  a  boy  twelve  years  old  in 
whose  thorax  the  clinical  diagnosis  of  aneurism  was  made.  The 
picture  shows  an  area  of  increased  density  in  the  region  of  the  great 
vessels  at  the  base  of  the  heart  in  the  fourth  left  interspace,  near  the 
edge  of  the  sternum,  and  its  interpretation  was  confirmatory  of  the 
cUnical  diagnosis.    The  rest  of  the  picture  was  normal. 


PLATK    107. 
NORMAL  THORAX. 

Girl,  age  7  years.     (Same  suhjccl  as  Plate  108.) 
(Dr.  Pkrcy  Huown.) 

Exposure  6  seconds. 

Child  breathing  normally. 

This  picture  was  taken  to  show  how  a  long  exposure  and 
the  child  respiring  gives  a  decidedly  hlui-red  outline  of  the 
heart  and  an  indefinite  lung  tissue  in  comparison  with  the 
results  of  a  short  exposure  as  shown  in  Plate  108. 


Pi.  ATE  107 


pi.Ai'i:  los. 

XOKMAI.  TIIoliAX. 

fiirl.  ape  7  years.     (Same  «iihject  as  Plate  107.) 

(Dh.  Pkrcy  Hkown.) 

Ex])osur(.'  1  f;ccon(l. 

Rt'spiration  arrested. 

Portrayal  of  the  internal  structures,  espeeiallx-  tin-  lungs, 
with  increa.sed  aceuracv,  in  comparison  with  thi'  results  shown 
in  Plate  107. 


Plate  108 


PLATE  109. 
ENLARGED  BRO.N'CHIAL  XODES. 

Girl,  ago  12  years. 

A  slightly  abnormal  condition. 

The  arrow  points  towards  some  enlarged  nodes  just  to  the 
right  of  the  outline  of  the  heart. 


Plate  109 

qGHT 


ri.ATi-;  111). 

TKAXSI'OSITIOX   OF   ORGAN'S.— TrBERClLl )SIS    OF   TIIK    HXCiS 
AND  HUOXCHIAI,  NODES. 

(lie.lucc.l  4(J%.) 

,4.  The  transpojspil  hoart. 

B.  Tho  liv(M'  transposoil  to  the  Irft. 

The  left  lunji'  ami  tlir  hi'oncliial  nmli's  show  iiiaiki'il  tiil)ri'- 
culosi.s. 


Plate  110 


LEFT 


PLATE   111. 

PNEUMOCOCCUS  LOBAR  PXEUMOXIA. 

Girl,  age  3  years.     (Reduced  33%.) 

The  arrow  points  to  a  consolidation  of  the  upper  lobe  of 
the  left  lung,  at  about  the  level  of  the  angle  of  the  scapula. 


Pl^TE  111 


m 


'1 


IM.ATi;  112. 

DOUBLE  PNEUMOCOCCUS  LOBAR  PNEUMOMA. 

Boy,  age  12  years.    (Reduced  42%.) 

A.  Consolidation  of  the  lower  lobo  on  tho  left  side. 

B.  Cousolidatiou  of  the  middle  and  lower  lobes  on  the  rijiht  side. 


Plate  112 


I 


">■      ■'«■■,■  f-i^ - 


,^—.-;-njtm-:x^-. 


PLATE  li:?. 
LOBAR  l'.\EU.\K)MA. 

OhiH,  age  10  yeurs.      (Reduced  427c..) 

.4.  Solidification  of  the  ri^i^ht  lower  lobe  with  an  area  sliowiiii; 
lesscniod  oonsoliilation  just  above  it.  Owini;  to  tlie  lack 
of  movement  in  the  lunf^,  ]jroduced  Ijy  its  solidification, 
the  bronchi  of  the  upper  lol)es,  especially  on  the  right, 
have  become  c|uite  distinct. 

B.  Consolidation  of  the  left  lower  lobe. 


Platk  ii;3 


I'l.A'i'i;  11 1. 

UXRESOLVED  LOBAR   I'NiaMdXIA. 

Cjirl,  age  4  years.     (Reiiuced  31%.) 

The  arrow  points  to  a  pneumonic  pi'occss  of  th(^  upi^cr  ri<>:ht 
lobe;  there  is  also  seen  in  tliis  ca.se  a  niarkcil  structural  ccm- 
srenital  scoliosis  to  the  risiht,  involvin.;;-  the  lowei-  dorstil  and 
uiijier  lumbar  vertebra'. 


Pirate  114 


PLATE   115. 
LOBAR  PNEUMONIA. 

Girl,  age  27  months.     (Reduced  28%.)     (Same  sulijert  as  Plates  d'l.  IIH,  and  117.) 

Right  upper  lobe  oitlu  r  unicsolvcil  or  a  beginning  cavity. 


PliATE  115 


I'l.ATi':  1  It;. 

CONSOLIDATIOX  ol'  Till':  UKllIT  tl'I'll!    IdHi;.      M()\(  loi.lAN 

miOT. 

Girl,  age  27  months.     (Saiiii'  Mjbjcc't  :i-  -Imwii  in  Plale-  ii.").  1  l."i   .•iii.l   117.) 

.1.    .\li   area   of  lessened   densily    lia,-.   a|i|ieare(l   in   I  he   Tiiiddle   of 
the  sdhdification.     Clinical  siuns  of  a  (^n'itv. 


Plate  116 


PI. ATI-;   117. 

(Reduced  31%.)     (Same  subject  .is  Plates  0.5,  11,5,  .ind  110.) 

The  area  of  density  A  shows  marked  increase  of  radia- 
bility.  In  the  lower  part  of  the  lung  the  process,  possibly 
tubercular,  is  seen  in  an  art^a  just  above  the  diaphra,<;m.  On 
the  left  side  the  bronchial  nodes  arc  plainly  seen  owing  to  the 
lessened  respiratory  movements  of  the  lung. 


Plate  117 


m 


""'^••-' 


■,VAjjTOti«jr^»a..-.  ^v--.<>'VMr..-v.: 


TI.ATi:   lis. 

BRON(!l(>rM;rMliM  A. 

CIliU],  age  4  years.     (Reiluced  42%.) 

Note  alveolar  infiltration   over  lower  ]iart   of  iip])ei'  lobes 
on  both  sides. 


Plate  ns 


^-  .    .-  •FOfy-*:' 


PLATE  119. 

PNEUMONIA  OF  THE  RIGHT  LUN'G  EOLLOWIXG  THE  INHALATION' 
OF  A  CHINA  DOLL'S  ARM. 

Girl,  age  4  years.     (Reduced  39%.)     (Same  subject  as  Plates  I4S,   149.  and  l.W.) 

Ari'ow  ])(iints  toward.-;  a  iniftinionic  area  in  the  right  up]jer 
lobe  produt-ed  l>y  the  arm. 


Plate  119 


PLAT]".   1-20. 
ACTTK  M11.IAI;^     ITBERCrLOSIS  (il'    I'lIK  I.l'XCS. 

Boy,  age  10  years.     (Keduoerl  494%. l 

General  fine  infiltration  over  the  vippei'  johcs  of  the  lungs. 
A.  Artifact. 


Plate  120 


■"  ■*■,".  -.t^T^   '  "V  *.^ 


}r,;-rr^" 


PLATE  121. 
EARLY  :\rTLl.\RY  TT'BKRCri.OSlS  (W  TTIK  l.T'XHS. 

A-c  :!  ,v.-ai>. 

ScattcMod  ureas,  cspeciiilly  marked  over  llic   middle  third 
of  the  right  lung. 


Pl.ATK  121 


m 


PLATl".   122. 
I'UOI'.ABI.K  OLD  TUBERCFLAIi   I'ltoCESS  OF  THE  RICIIP  I.IXG. 

Child,  age  12  ycar.s.     ^Relluce^l  431%.) 

.4.  Area  of  calcification. 

B.   Probably  an  active  ]irocoss  surrounding  .4. 


Plate  122 


PLATE  123. 

EMPHYSEMA,  GANGREXE,  AND  TUBERCULOSIS  OF  LEFT  LUNG. 
(VERIFIED  BY  AUTOPSY.) 

Girl,  age  3  years.     (Reduced  252%.) 

A.  Area  of  emphysema. 

B.  General    infiltration    of   miliary    tuberculosis.      Right    lung 

normal. 


Plate  123 


t 


I         , 


PLATE  124. 
ACUTE  MILIARY  TUBERCULOSIS  OF  BOTH  LUXGS. 

Girl,  age  12  years. 

The  arrows  i)oint  towards  the  tubercuhir  ^jrocesses. 


Pirate  124 


PLATE   125. 
HYDROPXEUMOTHORAX. 

Boy,  age  7  years,     (Same  subject  as  Plates  120  and  127.     "Pediatrics,"  iiftli  eciition, 

Plate  XIII.) 

The  picture  is  taken  with  the  l)oy  in  an  upright  position. 
The  level  of  the  effusion  on  the  left  side  is  elearly  shown,  as 
is  the  market]  displacement  of  the  heart  to  the  right. 


PliATE  125 


PLATK   12(). 
H^iTiROPXEUMOTHORAX. 

Boy.  age  7  years.     (Same  subject  as  Plates  125  and  127.     "Pediatrics."  fifth  edition. 

Plate  XIV.) 

The  picture  is  talcen  with  the  boy  lying  down. 

The  effusion  is  now  seen  to  occupy  nearly  all  the  left  chest 
with  the  exception  of  the  extreme  apex  of  the  lung-. 

The  cardiac  area  of  density  shows  tlie  heart  to  be  displaced 
to  the  right. 


Pr.ATE  126 


PLATE  127. 
PXEUMOTHORAX. 

Boy,  age  8  years.     (Same  subject  as  Plates  12.5  and  12('>,  taken  one  year  later.) 

Heart  displaced  to  right. 

The  arrow  points  to  a  greatly  increased  radiability  in  the 
left  lung. 


Pjlate  127 


PLATE  128. 
THICKENED  PLEURA. 

Boy,  age  6  years. 


Arrow  points  towanLs  the  dark  area  which  iiulifates  the 
pathologic  process. 


Pl^TE  128 


PLATE   129. 
PLEURISY  WITH  EFFUSION. 

Child,  age  8  years.     (Reduced  40%.) 

The  arrow  points  towards  the  effusion  which  fills  the  whole 
left  side  of  the  che.st,  with  possible  slight  disphieemciit  of  the 
heart  to  the  right. 


Plate  129 


^^ 


PLATE   130. 
COLLAPSE  OF  RIBS  OX  KKIIIT  SIDE  OF  THORAX. 

Girl,  age  G  years.     (Reduced  39%.) 

This  condition  followod  an  old  empyema  on  tlio  ri^ht  side, 
with  resulting  adhesions. 

Heart  displaced  to  right  and  held  there  by  adhesions. 
Compensatoiy  emphysema  in  left  lung. 
The  arrow  points  to  the  collapsed  ribs. 


Plate  130 


> 


•  ^^ '-' 


PUlTF.  131. 

ENCAPSULATED  EMPYEMA. 

Boy,  age  10  years.    (Reduced  45%.) 

Tho  arroT;\-  point.s  towards  an  encapsulated  empyema  at 
the  l)a.sc  of  the  right  king. 

This  case  was  operated  upon  and  the  Roentgen  diagnosis 
was  found  to  be  correct. 


PI.ATE  131 


PLATE   132. 

DILATED  HEART. 

Boy,  age  10  years.    (Reduced  48%.) 

The  arrow  points  towarcLs  a  distinct  cardiohepatic  angle. 


Plate  132 


PLATK   i:W. 
PERICARDIAL  KFITSION. 

Child,  age  12  ycurs.     iRfduceJ  45%.) 

.1  and/:?.   The  outlines  of  the  heart. 

C.  The  outline  of  the  disteiuled  ]ici-irardiiiiii  on  the  ri^ht. 
It  is  to  be  noted  that  the  cardioiieimtic  anule  is  ohliterated 


Pl,ate  133 


ri.ATI',   i:M. 
EXLAP.C.KI)  IIKAUT  WITH   I'llKICAKDI AI,  KFFUSIOX. 

C*IiiW,  age  12  years.     (Keducetl  -10%.) 

.1.  The  dilated  heart. 

B.  The  outline  between  the  dilateil  iK'art  and  the  effusion  on 

the  left. 

C.  ("ollap.sed  luni;;  tissue,  represent  ins;  very  well  the  appraranec 

which  would  he  found  in  atelectasis. 


Plate  134 


PLATl'.  i:i,-). 

PERICARDIAL  EFFI'SIOX  AND  OBLITERATION"  OF  TIIK  CAUDKV 
HEPATIC  ANGLE. 

(Reduced  45*<^r.l 

The  arrow  points  towards  a  i)i-ol)al)lc  ciTusiou  in  the  right 
pleura. 


PliATE  135 


PI. ATI;  i:5(). 
ANEUHISM. 

Boy,  age  12  years.    (Reduced  50%.) 

The  arrow  points  towards  an  increased  area  of  density 
just  above  the  base  of  the  heart,  on  the  left  side  of  the  ster- 
num, and  presents  the  clinical  signs  of  aneurism. 


PI.ATE  1.3G 


Division  VII 

THE   ABDOMEN 

Although  it  is  difficult  to  obtain  satisfactoiy  Roentgenographs 
of  the  abdominal  organs,  yet  great  advances  have  been  made  b}' 
using  new  methods.  A  striking  illustration  of  this  is  shown  in  Plates 
137  and  138. 

These  Roentgenographs  were  taken  by  Dr.  Percy  Brown  to 
show  the  greater  accuracy  of  outline  obtained  by  a  short  exposure, 
Plate  137,  seven  seconds,  the  child  not  breathing,  over  Plate  138, 
a  longer  one,  thirteen  seconds,  taken  during  normal  respiration.  The 
child  had  been  given  a  large  dose  of  bismuth  and  in  this  way  the 
resulting  great  density  was  obtained.  The  plates  illustrate  how 
the  comparatively  clean-cut  edge  of  the  stomach  shown  in  the  short 
exposure  is  contrasted  with  the  blurred  outline  of  the  long  exposure. 
There  are  a  niunber  of  congenital  malformations  of  the  intestine, 
represented  by  obliteration  of  the  intestine  from  various  causes,  such 
as  fibrous  bands,  yet  it  is  rare  that  we  can  show  these  conditions  bj' 
Roentgenographs.  The  malformations  of  the  oesophagus  and  stomach 
are  also  difficult  to  obtain  a  picture  of,  but  considerable  progress  is 
being  made  every  day  in  the  diagnosis  of  gastric  conditions. 

Plate  139  represents  the  stomach  of  an  infant  five  weeks  old, 
showing  the  so-called  hour-glass  contraction.  The  outline  of  the 
stomach  is  very  distinct,  especially  on  the  left  side  where  it  is  of  the 
normal  size,  whereas  on  the  right  side  it  is  very  small,  due  to  a  con- 
traction just  behind  the  lumbar  vertebrae.  This  gives  the  hour- 
glass appearance.  Otherwise  the  stomach  appears  to  be  normal. 
The  outline  of  the  intestine  is  distinctly  marked  below  that  of  the 
stomach. 

Plate  140  shows  the  stomach  of  the  same  subject  after  the 

141 


142  THE  ROENTGEN    ItAV   l.\   PllDIATRICS. 

hour-glass  contraction  has  boon  removed  by  the  inflation  of  tho 
stomach  with  air  through  a  soft  rubber  catheter. 

Wc  must  remember  that  as  our  technic  is  perfected  and  our 
powers  of  interpretation  increased  we  shall  probably  in  the  future 
understand  much  which  we  cannot  now  interpret,  although  we 
know  il  must  be  on  the  plate.  Especially  in  abdominal  cases  we  are 
probably  looking  at  conditions  which  are  undoubtedly  in  the  plate 
but  wliich  we  cannot  recognize. 

Plate  141  shows  the  picture  produced  by  a  fluid  in  the  abdo- 
men of  a  girl  twelve  j'ears  old.  The  picture  in  the  middle  is  darker 
than  at  the  sides,  which,  according  to  George,  is  on  account  of  the 
greater  depth  of  the  fluid  in  the  middle.  Dr.  George  also  interpreted 
the  dark  areas  above  tho  diaphragm  as  being  partiall}'  produced  by  a 
considerable  amount  of  a^dcma  which  was  present  in  this  case  and 
also  by  compression  of  the  lung. 

Plate  142  shows  what  appears  to  be  a  mass  of  enlarged  mesen- 
teric nodes  in  the  right  side  of  the  abdominal  cavity  in  a  child  ten 
or  eleven  years  old.  By  clinical  examination  it  was  impossible  to 
detect  hardened  faces  or  any  tumor  or  foreign  body.  As  the  child 
did  not  react  to  the  tuberculin  test,  the  diagnosis  as  to  whether  the 
enlarged  glands  were  of  tubercular  origin  was  left  in  abeyance. 


PLATE  137. 
NORMAL  ABDOMEX. 

Boy,  age  9  years.     {Same  subject  as  Plate  138.) 
(Dh.  I'kkc'y  Hrown.) 

Expcsure  of  stomucli  for  7  seconds,  with  respiration  (dia- 
phragm) arrested,  resulting  in  a  more  accurate  portrayal  of 
the  gastric  outline. 

Stomach  contains  about  one  ounce  of  bismuth. 

Note  sliarp  outline  of  .stomach  and  the  greater  clearness  of 
detail  in  comparison  with  the  same  subject  under  long  exposure 
shown  in  Plate  13S. 


PI.ATE  137 


PLATE  138. 
XORMAL  ABDOMEX. 

Boy,  age  9  j-ears.     (Same  suljjeot  as  Plate  137.) 
(Dk.  Pkkcy  Hkown.) 

Stomach  contains  about  one  ounce  of  bismuth. 

Long  exposure  of  the  stomach  for  13  seconds  (hiring  nornuil 
respiration. 

Note  the  bhirred  outHne  of  the  stomach  in  comparison 
with  the  sharply  defined  outhnc  and  general  picture  of  the 
same  child  under  short  exposure,  7  seconds,  shown  in  Plate  137. 


r 


Plate  l.'J.S 


PLATE  139. 

HOUR-GLASS  CONTRACTION  OF  STOMACH. 

Infant,  age  5  week.s.    (Reduced  20% .)    (Same  subject  as  Plate  140.) 

.4.   Distcnulcd  cardiac  end  of  stoiuacli. 

B.  Small   area   of   the   pyloric   end   of   the   stomach   ])artially 
separated  from  cardiac  end  by  contraction. 


Plate  1.39 


1 


L 


PLATE  140. 
hour-c;lass  contraction  of  stomach. 

.\ge  5  weeks.    (Reduced  163%.)     (Same  subject  as  Plate  139.) 

Stomach  distended  with  air  by  means  of  a  soft  ruljher 
catheter. 

.4.  The  cardiac  end  of  the  stomach  dilated  to  twice  the 
size  which  appeared  when  it  was  only  dilated  by 
the  contraction.  The  contraction  has  disap- 
peared, and  the  area  represented  l>y  C  still  shows 
a  slight  contraction. 

B.  Stomach-tube  lying  along  the  greater  curvature  of 
the  stomach. 

D.  The  distended  intestine. 


Plate  140 


PLATE  111. 
ABDOMIXAL  ASC'ITKS. 

Girl,  age  12  j^cars,     (Ra(luce<l  M't^/v.) 

The  broad  area  of  increased  density  in  tlu>  inidiUc  of  tl^c 
abdominal  area  represents  tlie  fluid,  and  is  marked  by  -4.  On 
(>ithcr  side  of  tliis  central  dark  area  are  areas  of  less  density 
which  represent  a  thinner  layer  of  fluid,  B. 


Platk  141 


4 


HHHlHi 


1  H^  I— I ' '  IM    1    I       ' 


I'LATK   112. 

CALCIFIED  MESENTERIC  XODES. 

(Reduced  35%.) 

The  arrow  points  to  an  area  of  increa.scd  density  just  to 
the  right  of  the  fourth  lumbar  vertebra.  Clinical  differentiation 
indicated  that  this  mass  represented  an  area  of  calcification. 


Plate  U2 


/ 


Division  VIII 

FOREIGN  BODIES 

The  importance  of  the  Roentgen  method  of  examination  for  the 
detection  of  foreign  bodies  has  now  been  recognized  for  some  time, 
and  its  vahie  is  increasing  every  day  as  our  knowledge  of  its  scope 
and  the  perfection  of  its  technic  increases.  Even  in  the  abdomen, 
which  usually  presents  such  difficulties  for  obtaining  a  satisfactory 
plate,  great  progress  has  been  made  in  the  line  of  diagnosis,  and  in 
the  near  future  we  shall  probably  receive  much  aid  from  the  ray  in 
differentiating  a  tubercular  mass  from  a  foreign  body.  Children 
are  so  much  more  apt  than  adults  to  swallow  or  inhale  foreign  bodies 
of  all  kinds,  that  the  role  which  the  Roentgen  ray  plays  in  this 
class  of  cases  has  become  an  important  ons. 

Plate  143  shows  a  stone  in  the  urethra  of  a  girl  thirteen  years 
old.  In  this  case  a  cystitis  had  existed  for  ten  years,  and  although 
the  child  had  never  been  considered  very  strong  she  was  bright  and 
active.  Even  as  early  as  her  third  year  she  had  complained  of 
painful  micturition,  and  the  pain  in  the  bladder  was  at  times  intense. 
At  no  time  had  the  relief  from  the  symptoms  been  complete,  relapses 
being  frequent.  The  Roentgenograph,  besides  showing  an  oval 
stone  approximately  the  size  of  a  moderate-sized  hen's  egg,  also  dis- 
closed in  the  centre  of  the  stone  a  bent  pin  with  a  distinct  head 
to  it.     The  stone  was  removed  by  operation. 

Plate  144  is  that  of  a  boy  five  years  old.  It  was  known  that  the 
child  had  swallowed  a  nail,  and  the  Roentgenograph  shows  dis- 
tinctly the  presence  of  the  nail  in  the  intestine. 

Plate  145  shows  a  penny  which  was  by  means  of  the  ray  de- 
tected in  the  oesophagus.  The  location  of  the  penny  having  been 
definitely  made  by  the  ray,  it  was  easily  removed  with  the  a^sopha- 
geal  forceps. 

143 


144  TIIK   H()K.\T(;K.\    liAV    IN    I'l'.DlATiaCS. 

Althoufih  tho  lodgcmcMit  of  a  foreign  body  in  tho  larynx  and 
trachoa  is  comparatively  rare,  it  t)ccurs  more  frequently  in  children 
than  in  adults.  The  symptoms  which  indii'ate  a  foreign  botly  are 
those  of  i-espiratory  obstruction.  It  is  very  important  that  the 
foreign  body  should  be  located  precisely,  and  this  is  best  accom- 
plished by  oljtaining  a  Roentgenograph.  Instrumental  localization 
of  any  kind,  on  account  of  the  danger  of  producing  a  sudden  inspir- 
ation, is  often  contraindicated.  The  pictm-e  tells  us  whether  instru- 
mental remo\al  should  be  attempted  or  tracheotomy  be  performed 
at  once. 

Plate  140  shows  the  definite  localization  made  by  the  ray  of  a 
hook  in  the  larynx  of  a  child  foiu-  >-ears  old.  It  had  been  noticed 
for  two  days  that  the  child  was  unable  to  cry  aloud  and  had 
difficulty  in  breathing.  The  hook  was  located  opposite  the  fifth 
intervertebral  cartilage  and  was  extracted  through  the  mouth. 

The  differential  diagnosis  to  be  made  by  the  ray  in  cases  of 
this  kind  is  from  acute  tracheal  laryngiHs,  ti'auma,  and  membra- 
nous laryngitis.  All  these,  however,  may  be  diagnosticated  by  other 
special  symptoms  directed  to  the  larynx  as  the  source  of  the  irri- 
tation. The  inferior  quality  of  this  electro-engraving  is  due  to  the 
difficulty  of  technic  in  these  cases. 

Plate  147  shows  a  nail  which  was  detected  in  the  lung  after  it 
had  been  there  for  five  years,  in  a  l)oy  twehe  years  old.  The  nail  is 
seen  in  the  right  lower  lobe.  It  had  been  inspirated  five  years  before 
tho  picture  w^as  taken,  and  was  not  suspected  at  that  time,  although 
a  Roentgenograph  had  been  taken.  The  boy  had  been  treated 
during  this  interval  of  five  years  for  ^'arious  diseases  of  the  lungs 
and  pleura.  The  Roentgenograph  shows  the  nail  surrounded  by  a 
dark  area  indicating  thickened  pleura  and  collapsed  lung.  In  the 
picture  will  be  noticed  a  dark  round  area  in  the  ninth  interspace  at 
about  the  posterior  axillary  line.     This  represents  a  piece  of  lead 


FOREIGN  BODIES.  145 

shot  placed  there  as  a  guide  at  the  time  of  the  first  operation,  after 
which  this  picture  was  taken.  The  tenth  rib  just  below  and  in  a  line 
with  the  shot  will  be  seen  to  have  been  resected  for  about  an  inch. 
It  will  be  noted  in  this  picture  that  there  is  practically  no  lung- 
tissue  in  the  right  lower  chest.  An  operation  was  not  successful, 
although  performed  twice. 

Plate  148,  the  same  case  as  Plate  119,  Division  \l.  shows 
the  presence  of  a  doll's  china  arm  which  was  inhaled  into  the 
lung.  The  history  of  this  case  is  of  considerable  interest.  A 
girl  four  years  old  entered  the  hospital  February  10,  1907,  with 
pulmonary  symptoms.  The  statement  was  made  that  she  had 
swallowed  the  arm  of  a  china  doll  in  October,  1905.  At  that  time 
she  became  cyanotic  and  had  a  severe  attack  of  coughing.  Since 
that  time  she  had  had  considerable  dyspnoea,  had  never  seemed  well, 
had  coughed  spasmodically  from  time  to  time,  but  had  been  up  and 
about  with  a  good  appetite,  sleeping  well,  and  with  no  history  of 
any  other  symptoms.  On  entering  the  hospital,  she  did  not  look 
very  well  and  her  temperature  was  102h°  F.,  respirations  62,  and 
pulse  165.  She  had  a  short  irritating  cough  and  there  was  a  marked 
dilatation  of  the  alse  nasi.  There  were  signs  of  consolidation  in  the 
lower  right  back  and  the  respiratory  excursions  were  greater  on  the 
left  side.  In  the  left  back  there  were  lessened  vocal  resonance  and 
tactile  fremitus,  and  at  about  the  middle  there  was  hyper-resonance 
over  an  area  of  5  cm.  in  diameter.  The  rest  of  the  physical  exami- 
nation was  negative.  There  was  a  leucocytosis  of  55,500.  The 
Roentgenograph  showed  a  pneumonic  process  corresponding  to  the 
clinical  examination  of  the  right  lung.  Nothing  was  shown  by  the 
raj^  in  the  left  lung.  The  pneumonic  condition  showed  well  in  the 
plate  but  is  not  so  satisfactory  in  the  electro-engra^■ing. 

Plate  149,  taken  February  10th,  shows  the  presence  of  the  for- 
eign body  (the  picture  is  reduced  35  per  cent,  and  the  plate  was  taken 

10 


11(5  Till';    ROHXTCiKX    KAV    1 X    I'llDIATKICS. 

with  tho  child's  faco  Winji  on  the  phito).  The  foroifj;n  l)0(ly  was 
as  seen  in  the  Hoentgenofiraph  1^  cm.  long  and  \  cm.  in  diameter, 
situated  at  the  junction  of  the  seventh  rib  with  the  left  edge  of  the 
sternum.  This  corresponded  to  the  jiiece  of  the  arm  which  had  been 
broken  off  from  the  child's  doll.  The  diagnosis  was  made  of  the  in- 
halation of  a  piece  of  a  china  arm,  occluding  probably  one  of  the  left 
bronchi,  and  followed  by  pneumonia  of  the  right  lung,  with  prob- 
able interference  of  expansion  of  the  left  lung,  as  an  aspiration 
of  the  left  chest  was  negative. 

Plate  150,  taken  Februai-y  lOth,  shows  the  same  picture.  The 
child's  symptoms  increased  in  severity,  but  the  white  count  dropped 
to  23,0U()  on  February  12th  and  to  18,300  on  February  13th.  The 
sputum  was  purulent  and  showed  numerous  micrococci.  No  tubercle 
bacilli,  influenza  bacilli,  or  pneumococci  were  present.  On  February 
L'Oth  there  were  a  few  pneumococci.  February  2r)th  the  white 
count  was  10,400  and  the  physical  signs  in  tlic  lungs  were  the  same. 

A  plate  taken  February  13th  showed  that  the  position  of  the 
arm  had  changed,  it  now  being  seen  between  the  sixtli  and 
seventh  ribs. 

A  plate  taken  February  14th  showed  the  position  of  the  arm 
to  be  about  the  same,  but  this  picture  was  taken  with  the  child 
h'ing  on  its  face  on  the  plate.  The  temperature  at  this  time  was 
ranging  from  99h°  to  101°  F.,  with  the  pulse  140  and  the  respirations 
150  to  160. 

The  child  coughed  up  the  china  arm  on  March  12th.  A  Roent- 
genograph was  immediately  taken,  and  it  was  found  that  the  pic- 
ture of  the  arm  had  disappeared,  but  that  the  pneumonic  process 
still  continued.     The  white  count  was  14,700. 

On  ^larch  2d  the  left  lung  was  practically  normal  and  there 
were  signs  of  resolution  in  tlie  right  lung. 

On  March  16th  the  cough,  dyspnoea,  and  general  symptoms  liad 


FOREIGX  BODIES.  1-17 

almost  disappeared  and  the  child  was  up  and  about  and  was  looking 
well.  The  temperature,  pulse,  and  respirations  were  practically 
normal  by  March  21st  and  the  signs  in  both  lungs  were  normal.  The 
child  was  discharged  well  March  28th. 

Although  the  bronchoscope  had  been  used  successfully  in  a 
number  of  cases,  it  was  not  deemed  advisable  after  a  few  attempts 
to  use  it  further  in  this  case,  as  the  Roentgenograph  showed  that 
the  arm  was  located  too  deeply  in  the  chest. 

Plate  151  shows  a  penny  localized  by  means  of  the  Roentgen 
ray  in  the  left  inguinal  region.  The  penny  is  seen  in  the  descending 
colon,  as  a  large  round  area  just  above  the  crest  of  the  ilium.  The 
outline  of  the  intestine  on  the  right  is  clearly  seen. 

Plate  86,  Division  III,  shows  a  needle  which  was  by  chance 
detected  in  the  right  hip  when  the  child  was  being  examined  for 
some  other  trouble. 

The  following  group  of  plates  shows  needles  in  various  parts 
of  the  body : 

Plate  152  shows  a  needle  in  the  knee-joint. 

Plate  153  shows  a  needle  in  the  knee  (same  case). 

Plate  154  shows  a  needle  in  the  dorsum  of  the  foot. 

Plate  155  shows  a  needle  among  the  tarsal  bones  and  in  close 

juxtaposition  to  the  cuneiform  bone. 
Plate  156  shows  a  needle  in  an  area  just  under  the  little  toe. 


PLATE   1  i;5. 
STONE  IX  URETHRA,  ENCAI'SULATIXC  A  PIX. 

Girl,  age  13  years.     (Actual  size.) 

Fig.  1.   RoENTGENOGR.\PH   OF  Stone   I.NTACT  AKTEK   Re.movau 

Fig.  2.  Stone  in  Ukethka. 

Fig.  '.i.   Photograph  op'  Stone  Broken  up  after  Removal. 


FIG.  1. 


PI.ATE  143 


FIG.   2. 


rr.ATK   144. 
FOREKJX  BODY  I.\  IXTESTIXE. 

Boy,  age  5  years.    (Reduced  37%.) 

A.  The  leader  points  towanl.s  an  increased  area  of  density 
caused  by  a  nail,  swallowed  Ijy  a  boy  5  years  old.  The 
peristaltic  action  of  the  intestine  has  rendered  the  outline 
of  the  nail  inilefinitc. 


PliATF,  144 


PI.ATK   145. 

FOREIGN  BODY  IN  (ESOPHAGUS. 

(Reduced  35%.) 

The  arrow  points  towards  a  round,  I'vcn  area  of  groat  den- 
sity, caused  by  an  old  Canadian  j^enny. 


Plate  145 


PLATK   llfi. 
HOOK  I.\  TIIIC  I.AIJVXX. 


('hiUI.  a^e  4  j'ear.s.     (Actual  size.) 


Plate  140 


PLATE  147. 

NAIL  IN  RKUIT  LUNG. 

The  arrow  points  towards  a  distinct  area  of  increased  den- 
sity, having  the  shape  of  a  nail,  and  at  about  the  junction  of 
the  ninth  rib  with  the  spine.  Just  to  the  right,  and  a  little  above 
in  the  sixth  interspace,  is  a  small  round  area  showing  great 
density;  this  represents  the  shot  used  as  a  guide. 


Plate  147 


PLATE  Its. 

DOLL'S  CHINA  ARM  L\  LUNO. 

Girl,  age  4  years.    (Reduced  35%.)    (Same  subject  as  Plates  119,  149,  and  ISO.) 

The  arrow  points  to  a  small  area  of  increased  density  at 
about  the  junction  of  the  seventh  rib  with  the  sternum,  on  the 
left  side. 


Plate  148 


*, 


"Wr^fS/'iT  <'">'*'' .'••'■/TKTCiVs^l'W    '  H^i 


KH 


PLATE  149. 

(Reduced  41%.)     (Same  subject  as  Plates  119,  148,  and  1.50.  but  taken  face  down  on 

the  plate.) 

The  iirea  of  density  indicatod  by  the  arrow  is  soon  to  be  a 
little  higher  and  about  the  junction  of  the  sixtli  rib  with  the 
left  edge  of  the  sternum. 


Plate  149 


PLATE   !.-)(). 

(Life  size.)     (Same  subject  as  Plates  ll'l,  14S,  and  149.) 

Shows  the  same  condition  a  little  more  clearly. 
The  arrow  ])oints  to  the  china  arm. 


Plate  150 


PLATE   151. 
PEXXY  IX  THE  DESCEXDIXC  COI.OX. 

tKiduceU  38%.) 

.1.   A   round   area  of  iiiarkod  density,  just    above  the  cr-sI   of 

the  ilium  (penny). 
B.   A  round   area  of  much  lessened  radiahility  eorresponding 

to  the  coils  of  one  of  the  intestines. 


PliATE  151 


i 


f 


PLATE   152. 
NE1':DLE  IX  THE  KNEE-JOINT. 

(Same  subject  as  Plate  lo3.) 

The  arrow  points  to  the  needle. 


PliATE  152 


PLATE   l.-)!?. 
NEEDLE  IX  THE   KXEE-JOIXT. 

(A  front  view  of  same  subject  as  Plate  152.) 

Tliis    ])ictun'   sliows   a    (UffenMit    position   of   the   leg,    thus 
giviiisr  the  exact  location  of  tlic  iiccdle. 


PliATE  l.");j 


I'LATK   l.-)L 
NEEDLK  IN  FOOT. 

(Same  subject  as  Plate  I5"j.) 

The  arrow  points  to  flu*  iictMllc 


PliATE  154 


PLATE  155. 
NEEDLE  IN  FOOT. 

(Actuul.^ize.)     (Same  subject  a.s  Plate  l.j4.) 

This  picture  shows  a  different  view  of  the  foot,  and  thns 
locates  the  needle  exactly. 

The  arrow  points  to  the  needle. 


PI.ATK   I.J.J 


/ 


*■■%. 


« 


•Li  iHMViaBML. 


PLATE  1->G. 

NEEDLE  IX  THE  TISSUES  AROUXD  THE  PHALANX  OF  THE 
LITTLE  TOE. 

(Kwlucerl  35%.) 

Tlie  arrow  points  to  the  needle. 


Plate  loO 


Division  IX 

THE  EXTREMITIES 

In  describing  the  diseases  of  the  extremities  which  can  be  de- 
tected by  the  Roentgen  ray,  we  are  deaUng  with  at  least  one-half  of 
the  information  about  diseased  conditions  which  can  be  obtained 
from  Roentgenographs.  In  this  varied  class  of  cases  it  is  especially 
necessary  to  use  the  utmost  care  in  the  differential  analyses,  the 
rules  for  which  I  have  already  given  in  the  Introduction.  It  is  also 
apparent  that  this  is  the  class  of  cases  where  it  is  absolutely  neces- 
sary thoroughly  to  study  and  master  at  least  the  gross  anatomy  of 
the  part  investigated.  This  is  all  the  more  difficult  and  important, 
as  the  anatomic  conditions  change  so  rapidly  in  early  Ufe  that  it 
is  not  a  question  of  the  normal  completed  anatomy  of  the  adult, 
represented  by  one  single  set  of  anatomic  pictures,  which  we  have 
to  interpret.  On  the  contrary,  it  is  the  numerous  sets  of  frequently 
changing  normal  pictures  which  it  is  necessary  for  us  to  recognize 
as  normal  in  order  to  determine  what  is  abnormal.  Of  especial 
significance  in  this  connection  are  the  difficulties  which  arise  in 
young  subjects  in  distinguishing  after  an  injury  whether  an  epiphysis 
has  been  separated  by  trauma  in  a  case  where  it  should  be  united 
normally  in  accordance  with  the  special  stage  of  development  of  the 
individual.  Often  this  can  only  be  accomplished  by  the  aid  of  the 
Roentgen  ray.  It  is  well  in  this  class  of  cases  to  train  the  eye  to 
recognize  any  differences  from  what  we  have  learned  to  consider 
normal  in  our  previous  study  of  living  anatomic  conditions  at 
different  periods  of  development  as  described  in  Divisions  I  and  II. 

IRREGULAR  DEVELOPMENT 

Hand. — As  an  example  of  retarded  development  is  the  hand  of 
a  child  eight  years  old  shown  in  Plate  157.     To  determine  whether 

149 


150  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

or  not  this  is  a  normal  hand,  we  should  first  turn  to  the  Roentgeno- 
graphs of  the  normal  hands,  which  have  been  described  in  Divi- 
sion II  as  indices  of  the  various  stages  of  development.  From 
a  comparison  with  these  wo  should  then  select  the  group  which 
corresponds  to  the  hand  of  this  child  eight  years  old.  On  doing 
this  we  find  that  Group  C,  which  represents  children  from  two  to 
three  years  old,  approaches  nearer  to  this  picture  than  to  any  of  the 
others;  while  the  group  which  would  correspond  to  the  normal 
development  of  a  child  eight  years  old  would  be  Group  J.  We  see 
at  once,  however,  that  this  hand  showing  delayed  development  is 
also  anomalous  in  its  t}npe,  even  if  the  child  were  only  two  or  three 
years  old.  An  anomaly  is  especially  noticeable  in  the  ver}'^  small 
epiphysis  of  the  radius,  which  corresponds  more  in  size  to  what 
would  usually  be  found  in  Group  H,  that  is,  in  children  about  six 
years  old.  The  carpal  bones,  only  three  in  number,  as  we  have 
already  stated,  would  place  this  hand  naturally  in  Group  C.  On 
examining,  however.  Group  C,  which  is  marked  by  the  os  magnum, 
unciform  and  cuneiform  bones,  we  see  that  the  epiphyses  of  the 
metacarpal  bones  are  present,  and  those  of  the  phalanges  also, 
while  this  hand  shows  a  total  absence  of  aU  the  epiphyses  of  both 
metacarpal  bones  and  phalanges.  So  far,  however,  as  the  bones 
themselves  are  concerned  they  simply  show  a  slight  deficiency  in 
the  Ume  salts. 

Wrist. — In  like  manner  if  we  compare,  as  is  shown  in  Plate 
158,  the  anomalous  radius  of  a  child  thirteen  years  old  with  that 
of  the  normal  hand  of  thirteen  years,  as  shown  in  Plate  40,  Group 
M,  some  decided  differences  will  be  detected.  This  occurs  in  the 
carpal  bones,  which  are  quite  as  well  developed  or  even  more  so 
than  in  Group  M.  They  also  show  quite  as  great,  if  not  greater 
development  of  the  epiphyses  of  the  metacarpal  bones  and  of  the 
proximal  ends  of   the  first  phalanges.     We  also  notice  the  early 


THE  EXTREMITIES.  151 

ossification  of  the  epiphysis  of  the  radius.  On  examining  closely 
we  see  that  this  epiphj^sis  of  the  radius  is  already  almost  com- 
pletely ossified.  The  epiphysis  of  the  ulna,  on  the  contrary,  has  not 
yet  completed  its  growth  and  will  be  seen  to  show  a  decidedly  de- 
layed development  in  comparison  with  that  of  the  normal  ulna, 
Plate  40,  Group  M,  where  it  has  practically  united  with  the  epiphy- 
sis. On  the  other  hand,  this  epiphysis  of  the  ulna  corresponds  very 
much  more  to  that  seen  in  Group  L,  a  child  about  twelve  years  old. 
It  is  very  evident  that  the  growth  of  this  ulna  is  not  yet  completed, 
and  its  development  will  not  be  completed  until  its  epiphysis  has 
become  completely  ossified.  The  radius,  on  the  other  hand,  having 
practically  completed  its  growth  as  regards  length,  will  always  be 
shorter  than  normal  in  comparison  with  the  ulna.  This  early  ossi- 
fication of  the  radius  probably  depended  upon  an  injury  to  the 
bone,  which  stopped  the  epiphyseal  growth  sooner  than  was  normal, 
while  the  uninjured  ulna  continued  to  grow.  It  is  interesting  in 
this  case  to  notice  the  sesamoid  bone  in  the  neighborhood  of  the 
metacarpal  bone  of  the  thumb  and  its  counterpart  in  the  normal 
hand,  Plate  40,  Group  M. 

Foot. — Plate  159  shows  the  scaphoid  of  the  left  foot  of  a  boy 
six  years  old.  For  two  or  three  weeks  it  had  been  noticed  that  this 
boy  limped  on  walking  and  favored  the  left  foot.  The  Roentgen 
examination  showed  a  very  much  undeveloped  scaphoid,  which  was 
not  sufficiently  supporting  the  arch  of  the  foot,  as  the  normal  sca- 
phoid of  the  same  period  of  development  should  do.  This  boy  had  a 
twin  brother  in  whom  the  Roentgen  ray  showed  the  same  unde- 
veloped condition  of  the  scaphoid,  but  to  whom  this  abnormality 
did  not  cause  any  trouble.  After  a  properly  adjusted  shoe  was 
applied  to  the  foot,  and  exercises  to  strengthen  the  muscles  were 
carried  out,  the  difficulty  was  obviated  and  the  lameness  passed 
away. 


152  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Femur  and  Tibia. — Plate  160  shows  the  early  ossification  of  the 
femur  and  tibia  in  a  boy.  Both  these  bones  remained  shorter  than 
they  should  have  been  if  their  normal  growth  had  continued.  This 
is  shown  in  the  complete  ossification  of  their  epiphyses.  On  the  other 
hand,  the  fibula  is  still  growing,  as  its  epiphysis  is  unossified.  There 
is  no  involvement  of  the  soft  parts.  The  tendon  of  the  quadriceps 
is  distinctly  shown.  On  the  lower  and  outer  surface  of  the  femur 
there  is  seen  to  be  a  slight  thickening  of  the  periosteum. 

Having  learned  to  interpret  these  cases  of  delayed  and  early 
ossification  we  can  next  study  such  conditions  as  are  abnormal 
from  various  causes  and  which  show  a  change  of  normal  outline. 
This  class  is  represented  by  such  conditions  as  swelling  of  the 
soft  tissues,  whether  in  the  muscles  or  in  the  periosteum,  and  by 
exostoses  of  the  bones.  The  recognition  of  these  changes  of  normal 
outline  and  density  is  often  of  great  value  in  that  it  clearly  and 
surely  shows  whether  the  bones  are  affected,  and  indicates  to  the 
surgeon  exactly  what  his  operative  procedure  should  be. 

ABSCESS 

Plate  161  shows  the  increased  densit}'^  and  local  increase  of 
outline  in  the  soft  tissues  around  the  left  humerus  in  a  boy  nine 
years  old.  A  subcutaneous  injection  had  been  given  at  this  point, 
and  there  was  so  much  tenderness,  swelling,  heat  and  redness  that  a 
Roentgenograph  was  taken  to  see  if  the  bone  was  affected.  As 
shown  by  the  picture  no  disturbance  of  the  bone  was  found,  and  the 
outline  of  the  cortex  was  seen  to  be  smooth,  even,  and  normal.  An 
operation  disclosed  an  abscess  of  the  soft  tissues. 

Plate  162  shows  a  swelling  of  the  soft  parts  over  the  heel  in  a 
boy  twelve  years  old.  It  will  be  seen  that  the  density  is  increased, 
the  radiability  being  lessened  on  account  of  a  hematoma  just  below 
the  OS  calcis.  The  epiphysis  of  the  os  calcis  shows  an  increase  in 
size  beyond  the  normal  epiphysis  at  this  age,  this  being  due  to  the 


THE  EXTREMITIES.  153 

increased  amount  of  blood  which  the  bone  has  received  into  its 
tissues.     The  other  bones  of  the  foot  and  ankle  are  normal. 

SARCOMA 

Myelogenous  sarcomata  are  rare  in  children,  but  may  occur  in 
or  about  the  larger  of  the  long  bones.  They  usually  attack  the 
shaft  of  the  bone  and  produce  changes  similar  to  certain  grades  of 
osteomyelitis,  differing  only  in  that  the  latter  presents  an  outhne 
showing  periosteal  reaction.  In  medullary  sarcomata  certain  areas 
of  increased  density  appear  which  resemble  spiculse  or  islands  of 
osseous  material  and  show  actual  absorption  of  the  bone,  with  none 
of  the  normal  portions  of  the  bone  remaining  about  this  point. 
Of  the  cases  seen  at  the  Children's  Hospital,  a  marked  increase  of 
tissue  has  been  apparent.  In  osteomyelitis  we  generally  have  a 
more  definite  proUferation  of  the  periosteum,  and  a  more  definite 
formation  of  new  bone  about  the  necrosed  area,  or  pieces  of  bone 
which  have  not  been  absorbed. 

Thigh. — Plate  163  shows  a  boy  four  and  a  half  years  old  with 
sarcoma  of  the  left  thigh. 

Fig.  1  shows  a  Roentgenograph  where  a  lateral  view  of  the 
femur  is  seen  wath  the  tumor  definitely  encapsulated  among  the 
muscles  of  the  thigh.  The  bone  is  showTi  to  be  perfectly  normal 
and  the  joint  is  not  involved  in  any  way.  The  mass  of  the  tumor 
can  easily  be  seen  through  the  surrounding  muscles  bj-  the  decreased 
radiability. 

The  photograph.  Fig.  2,  shows  a  swelling  of  the  posterior  region 
of  the  left  thigh,  with  a  bulging  both  on  the  inside  and  outside  of 
the  thigh  extending  down  into  the  popliteal  space. 

The  diagnosis  of  sarcoma  by  the  ray  was  proved  to  be  correct 
by  operation. 

Plate  164  shows  a  medullary  sarcoma  in  the  lower  part  of  the 
femur  of  a  child  about  twelve  years  old. 


154  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Plate  165  shows  a  periosteal  sarcoma  in  the  lower  part  of  the 
femur  of  a  boy  ten  years  old. 

ATROPHY 

Hand  and  Arm. — Plate  166  shows  an  outline  of  the  bones  of  the 
hand,  radius,  and  ulna,  which  is  seen  to  be  abnormal  in  comparison 
with  the  normal  bones.  This  picture  was  taken  from  a  boy  thirteen 
years  old,  and  shows  the  outlines  of  extreme  atrophy.  Between  the 
middle  of  the  shafts  of  both  bones  there  is  a  somewhat  suspicious 
appearance  suggesting  the  beginning  of  a  periostitis.  The  cause  of 
the  condition  in  this  child  was  unknown,  although  syphilis  was 
suspected  on  account  of  the  periosteal  thickening  of  both  radius 
and  ulna.  There  is  an  increased  radiability  of  both  radius  and  ulna, 
and  also  in  parts  of  the  bones  of  the  hand.  This  hand  and  lower 
arm  should  be  compared  with  the  normal  hand  of  about  the  same 
age  shown  in  Plate  40,  Group  M,  where  it  will  be  noticed  how  much 
larger  are  the  bones  and  how  much  greater  is  the  density. 

POLIOMYELITIS 

Hand. — Plate  167  shows  an  atrophy  in  quality  with  its  increased 
radiability,  and  also  an  atrophy  in  size  of  the  hand  of  an  infant  one 
and  a  half  years  old  in  its  sixth  week  of  an  attack  of  poliomyelitis 
anterior.  On  comparing  the  bones  of  the  right  hand  with  those  of 
the  normal  left  hand  the  atrophy  of  quality  is  especially  marked  and 
is  seen  in  all  the  bones,  radius,  ulna,  epiphysis  of  the  radius,  os  mag- 
num, unciform,  the  metacarpal  bones  and  the  phalanges,  with  their 
respective  epiphyses. 

Shoidders. — Plate  168  represents  the  shoulders  and  upper  arms 
of  an  infant  twelve  months  old.  The  left  shoulder  and  humerus 
show  the  results  of  an  attack  of  acute  poliomyelitis  of  six  weeks' 
duration.  The  humerus,  especially  at  its  neck,  is  seen  to  show 
increased  radiabihty  as  compared  with  the  other  side.  This  is  also 
well  shown  in  the  epiphysis.    The  increase  in  the  radiabihty  extends 


THE  EXTREMITIES.  155 

the  whole  length  of  the  bone.  There  is  a  slight  e\'idence  of  decrease 
in  the  radiability  of  the  scapula  and  of  the  acromial  process.  The 
thorax  and  chest  are  those  of  a  perfectly  normal  child. 

Elbow  and  Wrist. — Plate  169  shows  the  elbow,  lower  arm,  and 
wrist  of  a  child  four  years  old,  with  marked  atrophy  of  the  muscles 
and  bone  following  an  attack  of  poliomyelitis  anterior.  To  be 
especially  noted  is  the  atrophy  in  size  and  also  in  quahty  of  the 
carpal  bones  and  of  the  radius  and  ulna.  The  atrophic  condition  of 
the  muscle  is  not  especially  well  shown  in  the  reproduction,  but  in 
the  original  plate  was  well  marked. 

SUBPERIOSTEAL  HEMORRMAQE 

Thigh. — Plate  170  shows  the  change  from  the  normal  outUne 
caused  by  an  injury  to  the  thigh  followed  by  a  subperiosteal  hemor- 
rhage. The  periosteum  is  seen  to  be  stripped  from  almost  the  entire 
length  of  the  femur,  and  the  resulting  clot  to  have  become  organ- 
ized.   The  plate  represents  a  side  \'iew  of  the  thigh. 

EXOSTOSES 

Exostoses  of  the  bones  and  allied  conditions  are  comparatively 
rare  in  children,  though  occasional  cases  are  seen  in  which  an  exam- 
ination by  the  Roentgen  ray  demonstrates  that  in  all  the  epiphyses 
or  near  the  epiphyses  of  the  body  rough  irregularities  or  formations 
of  new  bone  appear  with  distortion  of  the  bone  at  these  points. 
Occasionally  only  a  single  exostosis  is  seen.  This  condition  usually 
occurs  in  children  in  or  about  the  epiphA'ses.  The  exostoses  show  a 
definite  bone  structure  generally,  but  they  may  take  a  more  or  less 
fantastic  shape.  The  normal  bone  about  the  exostoses  does  not 
change  in  any  way.  The  cause  of  these  exostoses,  whether  the 
condition  is  multiple  or  single,  is  somewhat  obscure.  Infection  and 
traumatism  represent  in  part  the  cause  of  the  single  exostoses. 
They  may  arise  from  a  number  of  infections,  such  as  scarlet  fever. 


156  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Astragalus. — Plate  171  shows  an  exostosis  of  the  astragalus  in 
a  child  twelve  years  old.  The  outgrowth  is  shown  on  the  anterior 
surface  of  the  bone  and  appeared  as  a  sequela  of  scarlet  fever. 

Tibia  and  Fibula. — Plate  172  shows  the  lesions  of  a  case  of 
multiple  exostoses  in  a  child  five  years  old.  The  change  in  the  nor- 
mal outline  of  the  bones  of  the  fibula  and  tibia  will  at  once  be  recog- 
nized. Especially  to  be  noted  is  the  exostosis  at  the  inner  side  of 
the  upper  diaphysis  in  comparison  with  the  clear-cut  line  of  the 
lower  diaphysis  ,of  the  right  tibia.  In  this  case  practically  all  the 
bones  of  the  body  had  similar  exostoses. 

Knee. — Plate  173  shows  a  well-marked  case  of  multiple  exos- 
toses in  the  neighborhood  of  the  knee-joint  in  a  boy  five  years  old. 
There  is  a  very  evident  new  formation  of  bone  at  the  lower  end  of 
the  femur.  The  upper  end  of  the  fibula  shows  an  irregular  and  dis- 
torted appearance  with  a  complete  absence  of  its  epiphysis.  The 
inner  and  upper  edge  of  the  tibia  also  shows  an  exostosis.  In  this 
case  there  is  seen  to  be  a  considerable  change  in  the  quality  of  the 
bones,  as  well  as  the  change  in  shape. 

Femur. — Plate  174  shows  an  exostosis  of  the  lower  end  of  the 
femur. 

Plate  175  shows  an  exostosis  of  the  upper  part  of  the  right 
tibia  in  a  boy  twelve  years  old.  This  picture  also  shows  a  number 
of  narrow  transverse  lines  passing  across  the  whole  front  of  the 
diaphysis.  These  are  supposed  to  be  the  remains  of  old  ossified 
epiphyseal  lines. 

CALLUS 

Plate  176  shows  the  feet  of  a  girl  ten  years  old.  A  year  previous 
to  being  seen  a  set  of  steel  plates  had  been  prescribed  for  her  by  a 
physician,  supposedly  for  the  breaking  down  of  the  arch  of  her  foot. 
She  had  worn  the  plates  continuously  and  showed  on  the  inner  sur- 
face of  each  foot  in  the  region  of  the  scaphoids  a  hard  thickened 


THE  EXTREMITIES.  157 

callus.  The  Roentgenograph  was  taken  in  order  to  discover  whether 
there  were  any  malformations  or  exostoses  of  the  bones  of  the  feet. 
The  lesions  evidently  came  from  wearing  badly  fitting  plates,  and 
an  examination  with  the  Roentgen  ray  showed  that  the  arch  was 
not  broken  down,  Plate  177,  but  on  the  contrary  was  higher  than 
usual.  It  also  showed  the  outer  surface  of  the  scaphoid  on  the  left 
foot  to  be  somewhat  irregular,  a  little  roughened  and  with  lessened 
radiability.  In  comparison  with  the  right  foot,  which  is  normal,  it 
is  seen  how  much  smaller  is  the  border  line  of  the  left  tarsus,  and 
the  arch  of  the  foot  is  rather  higher  than  normal.  The  plates  were 
removed  and  the  thick  callus  formation  gradually  disappeared. 

FLAT-FOOT 

Plate  178  shows  the  condition  of  moderate  fiat-foot  in  compari- 
son with  the  high  instep  just  shown  in  Plate  177. 

TRAUMATISM 

Traumatism  in  children  plays  an  important  part,  in  that  sec- 
ondary changes  due  to  injuries  to  the  different  tissues  and  bones  of 
the  skeleton  may  occur,  which  disturb,  either  by  actual  destruction 
of  bone  or  by  injurj^  to  the  epiphyses,  the  growth  and  the  future 
usefulness  of  a  given  bone  or  joint. 

The  lesions  of  the  extremities  which  are  most  readily  detected 
by  the  ray  are  those  which  are  produced  by  traumatism.  The  most 
exact  knowledge  of  the  epiphyseal  Unes  and  of  the  epiphyses,  as  to 
their  normal  development  at  different  periods  of  growth  and  when 
they  become  united  to  their  diaphyses,  is  a  prerequisite  for  the 
correct  interpretation  of  the  many  disturbances  which  result  from  a 
traumatism  of  these  parts  in  early  life.  In  J.  S.  Stone's  admirable 
monograph  on  acute  epiphyseal  and  periosteal  infections  in  infants 
and  children,  he  states  that  among  infants  and  children  many  le- 
sions of  the  bones  and  joints  are  seen  which  differ  materially  from 
those  which  occur  in  adults.    The  character  of  all  lesions  involving 


158  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

the  bones  of  infants  and  children  depends  largely  on  the  anatomy 
of  the  epiphyses  and  to  a  less  extent  on  that  of  the  periosteum. 
This  is  true  whether  the  cause  is  traumatic  or  infectious.  The 
epiphyseal  lines  are  a  very  frequent  seat  of  infection,  are  a  source 
of  mechanical  weakness,  and  are  the  seat  of  numerous  lesions. 
The  strong  periosteum  is  a  source  of  mechanical  strength,  but  influ- 
ences the  spread  of  infectious  processes.  Epiphyseal  separations 
are  generally  regarded  as  very  similar  to  fractures.  In  infants  and  in 
young  children  there  must  be  innumerable  injuries  to  the  epiphyses 
which  pass  unrecognized,  since  the  lesions  cannot  be  demonstrated 
clinically.  In  relatively  severe  injuries  to  the  epiphj'ses  localized 
tenderness,  and  perhaps  some  swelling  with  disturbance  of  func- 
tion, are  the  only  signs  which  can  be  detected.  An  intimate 
knowledge  of  the  epiphyseal  lines,  therefore,  and  of  the  gradual 
appearance  and  ossification  of  the  epiphyses  is  especially  necessary. 
Of  much  interest  also  are  the  degrees  of  separation  and  the  final  per- 
manent attachment  of  the  condyles  and  of  the  tuberosities,  abnormal 
conditions  of  which,  such  as  separations  and  displacements,  are  of 
interest  to  both  physician  and  surgeon.  This  is  true  not  only  from 
their  relation  to  treatment,  but  from  a  medicolegal  point  of  view, 
and  from  their  liability  to  provide  a  nidus  for  the  dissemination  of 
infectious  processes. 

Since  the  Roentgen  ray  has  come  into  use  so  extensively  the 
study  by  it  of  injuries  to  the  osseous  system  has  been  of  great 
assistance  and  value  to  the  surgeon.  Fractures  heretofore  unrecog- 
nized or  seldom  recognized  can  now  be  easily  detected,  indeed 
fractures  of  all  kinds  have  been  diagnosticated  much  more  com- 
monly since  the  Roentgen  method  has  been  used  systematically. 

The  technic  in  the  Roentgen  examination  of  cases  of  trauma- 
tism or  suspected  fractures  of  any  of  the  bones  is  important  in 
certain  details. 


THE  EXTREMITIES.  159 

First,  that  the  part  to  be  examined,  as  for  instance  the  wrist- 
joint,  should  be  carefully  immobilized  and  the  tube  centred  directly 
over  the  part  suspected. 

Second,  two  views,  one  at  right  angles  to  the  other,  should  be 
taken,  that  is,  an  anteroposterior  view  and  a  lateral.  In  all  cases 
of  fractures  of  the  bones  in  which  these  two  views  are  accessible, 
such  as  the  long  bones,  and  with  the  exception  of  the  shoulder  and 
hip-joint,  this  examination  should  be  made  as  a  matter  of  routine. 

Third,  it  is  better  to  have  the  cases  examined  without  dressings, 
such  as  splints  or  plaster.  If  this  is  contraindicated  for  any  reason, 
it  must  be  borne  in  mind  that  there  will  be  an  increase  in  the  general 
size  of  the  part  under  examination.  Aside  from  this,  however,  there 
will  be  no  actual  distortion,  so  that  the  relations  of  the  part  will  be 
the  same  one  to  another. 

I  shall  present  a  few  illustrations  of  the  various  forms  of  trau- 
matism, such  as  separation  of  the  epiphyses,  dislocations,  and 
fractures.  These  injuries  are  so  common  and  so  varied  that  I 
shall  speak  only  of  a  few  representative  traumata,  a  thorough 
study  of  which  will  aid  very  much  in  the  diagnosis  of  other 
injuries  of  the  same  parts. 

Knee. — Plate  179  represents  an  injury  to  the  knee-joint  in  a 
child  twelve  years  old.  The  Roentgenograph  shows  that  the  inner 
condyle  of  the  femur  has  been  displaced  backwards.  The  epiphys- 
eal cartilage  is  rough  and  irregular  along  its  posterior  two-thirds. 
There  is  a  slight  tissue-reaction  in  the  knee-joint  as  shown  by  hazi- 
ness.  The  shafts  of  the  femur,  tibia,  and  fibula  are  perfectly  normal. 

Epiphysis  and  Shaft  of  Humerus. — Plate  180  shows  a  complete 
dislocation  of  the  epiphysis  and  a  marked  displacement  of  the  shaft 
of  the  humerus.  It  also  shows  a  complete  fracture  of  the  head  of 
the  humerus. 

Fracture  of  Humerus. — Plate  181  shows  a  fracture  of  the  shaft 


160  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

of  the  humerus  in  a  boy  eleven  years  old  which  gave  the  clinical 
picture  of  a  dislocation  rather  than  a  fracture.  There  is,  however,  a 
complete  transverse  fracture  at  the  anatomical  neck  of  the  humerus. 

Frachire  of  Sxirgical  Neck  of  Humerus. — Plate  182  shows  a  slight 
amount  of  displacement  of  the  shaft  of  the  humerus  of  a  boy  twelve 
years  old.  There  is  also  a  fracture  of  the  surgical  neck  of  the 
humerus. 

In  regard  to  the  locality  of  various  injuries  it  may  be  stated 
that  fractures  of  the  ribs  in  children  are  rather  rare,  as  the  ribs  are 
very  pliable  and  stand  a  comparatively  greater  strain  than  they  do 
in  adults. 

Fractures  of  the  bones  that  make  up  the  shoulder  in  children, 
with  the  exception  of  the  clavicle,  are  comparatively  rare,  and  here, 
again,  the  importance  of  considering  the  normal  anatomy  of  the 
shoulder-joint  at  different  ages  becomes  important. 

Fracture  of  Humerus. — Plate  183  shows  a  fracture  of  the  hu- 
merus in  a  child  four  years  old.  This  picture  was  taken  through  the 
dressings  and  shows  a  break  in  the  continuity  of  the  outer  border  of 
the  humerus  in  the  region  of  the  surgical  neck  with  a  slight  impac- 
tion of  the  shaft.    Otherwise  the  bones  are  normal. 

Knee-joint:  Dislocation  and  Fracture. — Plate  184  represents  a 
dislocation  of  the  epiphysis  of  the  femur  and  a  fracture  of  the  con- 
dyle in  a  boy  five  years  old,  and  shows  a  lateral  view  of  the  knee- 
joint.  The  picture  shows  a  complete  transverse  fracture  and  back- 
ward dislocation  of  the  condyle  with  new  formation  of  bone  at  the 
lower  end  of  the  femur  which  unites  with  the  dislocated  epiphysis. 
No  changes  in  the  shafts  of  the  bones  are  present. 

Tibia:  Green-stick  Fracture. — Plate  185  shows  the  result  of  an 
untreated  green-stick  fracture  at  the  lower  third  of  the  tibia.  The 
tibia  in  this  region  seems  to  be  irregular  in  outline,  and  there  is  an 
increase  on  its  concave  side.     This  consists  of  an  increase  of  the 


THE  EXTREMITIES.  l(il 

periosteum  and  of  the  cortical  substance  of  the  bone.  There  is  a 
slight  increase  in  radiability  at  the  lower  end  of  the  tibia  with 
sUghtly  decreased  radiabihty  in  the  same  region  of  the  fibula.  The 
epiphyseal  lines,  however,  are  normal. 

Femur:  Intracapsular  Fracture. — Plate  186  shows  an  intracap- 
sular fracture  of  the  femur  in  a  boy  ten  years  old.  The  whole  joint 
is  rather  hazy,  but  along  the  acetabulum  is  seen  the  separated 
epiphysis  of  the  femur.  The  femur  itself  shows  some  increased 
radiability. 

Knee-joint;  Femur:  Dislocation  of  Epiphysis  and  Condyle. — 
Plate  187  shows  the  knee-joint  of  a  boy  ten  years  old,  with  the 
epiphysis  and  the  inner  condyle  dislocated  from  the  lower  end  of 
the  femur.  Otherwise  the  structure  of  the  bones  is  practically 
normal. 

Humerus:  Fracture. — Plate  188  represents  a  fracture  of  the 
lower  end  of  the  humerus  in  a  child  ten  years  old.  The  picture 
shows  a  transverse  fracture  of  the  lower  end  of  the  shaft  of  the 
humerus  with  displacement  of  the  lower  fragments  inwards.  In 
this  case  the  condition  was  considered  clinically  a  perfect  reduction. 

Radius:  Green-stick  Fracture. — Plate  189  shows  a  green-stick 
fracture  of  the  radius  occurring  in  a  child  twelve  years  old.  As 
shown  by  the  grayish-white,  faint  transverse  line  in  the  lower  third 
of  the  radius,  there  is  a  break,  but  the  periosteum  has  not  broken 
through,  the  break  being  in  the  cortical  and  medullary  portion  of 
the  bone.  The  irregular  areas  in  the  plate  show  parts  of  the  band- 
age, and  we  should  remember,  as  I  have  explained  before,  that 
although  the  details  of  the  parts  are  not  altered  on  this  account 
the  whole  picture  is  somewhat  larger  than  it  otherwise  would  be. 

Radius  and  Ulna:  Impacted  Fracture. — Plate  190  shows  a  com- 
plete transverse  fracture  with  shght  impaction  of  both  radius  and 

ulna  in  a  boy  between  three  and  four  years  old.    At  the  top  of  the 
11 


162  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

picture  are  to  be  noted  the  proximal  ends  of  the  first  phalanges, 
and  also  the  fingera  of  the  hand  of  the  assistant  who  was  holding  the 
child's  fingers  down.  Also  to  be  noted  is  the  development  of  the 
lower  epiphysis  of  the  radius,  which  corresponds  to  the  anatomical 
Group  D,  from  three  to  four  years. 

Radius  and  Ulna:  Fracture. — Plate  191  shows  a  complete  frac- 
ture of  the  radius  and  ulna  in  a  child  three  years  old.  The  Roent- 
genograph is  taken  through  the  splint  after  the  fracture  had  been 
reduced.  The  capitellum,  as  it  appears  in  the  elbow-joint  close  to 
the  lower  end  of  the  humerus,  is  normal  at  this  age. 

Tibia:  Fracture. — Plate  192  shows  the  otherwise  normal  foot  of 
a  child  twelve  months  old,  with  a  small  incomplete  fracture  just 
above  the  lower  epiphyseal  line  of  the  tibia  on  the  anterior  surface. 
The  rupture  of  the  tendo  Achillis  is  well  marked.  The  fracture 
occurred  at  the  time  the  child  was  being  treated  for  the  correction 
of  club-foot. 

Astragalus:  Fracture. — Plate  193  shows  a  fracture  of  the  astraga- 
lus in  a  boy  eleven  years  old.  The  bones  of  the  foot  are  normal  with 
the  exception  of  the  astragalus,  which  shows  a  complete  fracture 
in  its  upper  third.  This  fracture  was  due  to  catching  the  foot  in  a 
revolving  wheel. 

Tibia  and  Fibula:  Fracture  and  Abscess. — Plate  194  shows  an 
abnormal  condition  at  the  lower  end  of  the  tibia  and  fibula  with  a 
bridge  uniting  the  two,  which  seems  to  represent  the  osseous  con- 
nection of  an  old  fracture.  The  lower  end  of  the  tibia  and  the  bones 
of  the  foot  are  seen  to  be  very  finely  pencilled,  indicating  a  marked 
lime  absorption.  Posterior  to  the  epiphysis  of  the  fibula  there  is 
seen  to  be  a  definite  swelUng  of  the  soft  parts  due  to  the  forma- 
tion of  an  abscess.  The  whole  foot  illustrates  a  tubercular  process 
with  the  formation  of  an  abscess  but  without  actual  destruction 
of  the  bone. 


THE  EXTREMITIES.  163 

Os  Calcis:  Fracture  of  Epiphysis. — Plate  195  shows  a  fracture  of 
the  epiphysis  of  the  os  calcis  in  a  child  ten  years  old.  Clinically 
this  child  had  marked  pain  and  tenderness  over  the  region  of  the 
heel.  In  making  a  differential  diagnosis  of  this  lesion  we  must 
remember  that  the  epiphysis  of  the  os  calcis  sometimes  unites  by 
two  centres  and  gives  this  same  appearance  at  this  age.  Mobiliza- 
tion of  the  heel  in  this  case  gave  relief,  and  the  supposition  there- 
fore was  that  it  was  a  fracture.  Cases  of  this  kind  enunciate  very 
strongly  the  importance  of  avoiding  the  overlooking  of  slight  frac- 
tures by  calling  to  our  aid  an  examination  by  the  Roentgen  ray. 
Especially  is  this  important  in  children,  who  often  can  be  relieved 
of  their  pain  and  general  discomfort  at  once  as  soon  as  the  seat  of 
the  lesion  has  been  located,  while  unless  we  do  ascertain  this  by 
means  of  the  ray  the  lesion  not  only  might  not  recover  rapidly,  but 
might  even  be  increased  in  its  severity  with  a  possible  final  result  of 
impaired  usefulness  of  the  part. 

Tibia:  Fracture. — Plate  196  shows  a  condition  arising  from  an 
ununited  fracture  of  the  tibia  in  the  left  leg  of  a  girl  twelve  years 
old.  The  fracture  is  in  the  middle  and  upper  third  of  the  tibia  and 
shows  an  attempt  to  unite.  The  whole  tibia  shows  marked  atrophy, 
not  only  in  thickness  but  also  in  length  and  quality,  as  shown  by 
the  greatly  increased  radiability  of  the  shaft.  The  fibula,  however, 
shows  a  compensatory  increase  in  size  and  decrease  in  radiability. 
It  has  practically  taken  up  the  function  of  the  tibia.  The  right  leg 
is  normal  in  every  respect  for  this  age,  and  the  injured  leg  should  be 
carefully  compared  with  it. 

JOINTS 

There  has  been  a  great  deal  of  discussion  concerning  the  proper 
classification  of  conditions  in  which  the  joints  are  affected.  In  our 
efforts  to  decide  upon  a  rational  and  correct  nomenclature,  much 
opposition  has  arisen  from  the  fact  that  physicians  are  loath  to 


164  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

change  the  names  by  which  they  have  been  accustomed  to  recog- 
nize, or  rather  think  that  they  recognize,  certain  groups  of  chnical 
symptoms.  One  of  the  reasons  for  this  is  that  they  do  not  appreciate 
that  the  same  clinical  symptoms  may  be  produced  by  a  number  of 
different  etiologic  factors,  and  that  again  these  factors  in  their  origin 
may  simply  arise  from  traumatism  without  specific  infection,  or 
again  may  arise  from  a  large  number  of  different  specific  infections. 
So  long,  therefore,  as  a  classification  on  a  clinical  and  symptomatic 
basis  is  retained,  no  advance  can  be  made  in  the  proper  and  intelli- 
gent understanding  of  the  different  diseases.  On  the  other  hand, 
there  are  those  who  prefer  a  pathologic  classification.  Here,  again, 
the  mistake  is  made  in  thinking  that  precise  and  exact  pathologic 
conditions  always  correspond  to  a  specific  etiology.  In  quite  a  large 
number  of  pathologic  conditions  which  are  found  at  the  autopsy 
there  is  no  doubt  that  the  lesions  do  not  necessarily  arise  from  one 
specific  cause.  On  the  contrary  they  are  merely  terminal  lesions 
which  may  represent  a  number  of  different  primary  conditions 
of  a  special  disease.  When  we  consider  that  in  most  cases  we  have 
had  to  wait  until  the  patient  has  died  in  order  to  discover  what  the 
lesions  were  which  corresponded  to  his  special  symptoms,  it  is  no 
wonder  that  such  confusion  has  arisen  from  our  having  to  depend 
upon  dead  patholog}'.  It  is  very  evident  also  that  now  that  we  are 
enabled  to  study  living  pathology  by  means  of  the  Roentgen  method 
a  great  advance  can  be  made  in  classification.  We  can  often  recog- 
nize the  early  lesions  of  a  special  disease,  and  taking  advantage 
of  this  we  can  eventually  sweep  away  the  false  position  and  result- 
ing obscure  ideas  which  we  have  arrived  at  from  our  study  of 
the  lesions  represented  by  dead  pathology.  The  truth  of  what  I 
have  just  said  is  manifest  when  we  come  to  consider  disturbances  of 
the  joints,  whether  from  simple  congestion,  trauma,  without  infec- 
tion or  followed  by  infection,  or  infection  without  trauma  by  direct 


THE  EXTREMITIES.  165 

infection  of  the  part  through  the  blood.  In  approaching  this  subject 
we  would  naturally  begin  with  those  affections  of  the  joints  which 
might  be  considered  non-infectious,  and  to  be  the  result  of  trau- 
matism. In  quite  a  number  of  cases  where  I  have  been  unable  to 
determine  in  a  lesion  of  the  joint  that  the  resulting  pathologic  con- 
dition has  arisen  from  an  infection,  and  therefore  is  a  so-called 
idiopathic  disturbance  of  the  joint,  I  have  had  to  assume  for  the 
time  being  that  I  was  dealing  with  an  injury  without  infection.  Cer- 
tain acute  conditions  of  a  joint,  especially  of  the  knee,  will,  following 
an  acute  injury,  present  the  symptoms  of  heat,  swelling,  tenderness, 
effusion  into  the  joint,  with  absorption  and  complete  recovery.  This 
sequence  of  symptoms  has  so  frequently  been  met  with  that  it  per- 
haps seems  hard  to  beUeve  that  infection  has  taken  place  in  any 
way  etiologically.  It  is  very  probable,  however,  that  in  the  future 
the  number  of  cases  which  will  be  proved  to  be  non-infectious  will 
grow  less  and  less  as  our  knowledge  of  infectious  processes  increases, 
and  when  our  power  of  detecting  specific  organisms  is  more  perfected. 
A  specific  organism  may  have  a  brief  clinical  history.  It  may  be  so 
benign  that  its  effect  simply  represents  an  acute  disease  running  a 
very  rapid  course  and  tending  to  recover.  We  must  for  the  present, 
therefore,  allow  that  the  whole  subject  is  sub  judice.  I  would,  how- 
ever, enunciate  the  general  principle  that  the  only  safe  course  to 
take  in  any  injury  of  the  joint,  whether  from  mild,  or  moderate,  or 
severe  trauma,  is  that  it  should  be  at  once  treated  as  though  possibly 
an  infection  had  taken  place  or  might  take  place  very  shortly.  Only 
in  this  way  can  we  avoid  the  mistakes  which  we  see  made  over  and 
over  again,  when  a  slight  trauma  is  passed  over  without  much 
notice. 

I  shall  not  attempt  to  make  any  classification  of  this  set  of 
cases,  as  it  is  hardly  within  the  scope  of  the  work  in  which  I  am 
now  engaged.     I  merely  wish  to  show  the  living  pathology  of  the 


166  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

joints  with  the  same  idea  in  view  as  when  we  study  the  dead  pathol- 
ogj'.  For  instance,  I  shall  show  what  an  inflamed  congested  joint 
looks  like  in  a  Roentgenograph:  the  appearances  which  are  met 
with  in  the  different  disturbances  of  the  diaphysis:  the  epiphyseal 
line:  the  epiphyses :  the  capsular  lining  of  the  joint:  the  appearance 
when  an  effusion  is  present;  the  appearance  when  resulting  adhe- 
sions have  taken  place,  or  still  further  that  villous  formation  which 
is  the  result  of  a  number  of  pathologic  conditions  of  the  joints.  Hav- 
ing learned  to  recognize  the  different  lesions  which  may  occur  in 
acute  and  chronic  processes,  we  are  in  a  position  to  discuss  the  lesions 
which  result  from  various  disturbances  of  the  joints. 

Following  out  this  idea  I  shall  now  refer  to  some  plates  which 
represent  a  few  of  the  lesions  which  are  met  early  and  late  in  disturb- 
ances of  the  knee-joint,  whether  traumatic  or  infectious. 

Knee:  Congestion. — Plate  197  illustrates  the  results  of  a  con- 
gestion of  the  knee  of  a  boy  six  years  old.  There  is  seen  to  be  an 
hypertrophy  in  the  size  of  the  epiphyses  of  both  femur  and  tibia  in 
the  left  knee  in  comparison  with  the  right.  There  is  also  increased 
radiability  in  the  epiphyses  on  the  left.  In  addition  to  this  there  is 
some  thickening  of  the  soft  parts  and  capsule  around  the  knee- 
joint.  The  epiphyseal  line  of  the  femur  and  tibia  is  comparatively 
normal.  The  epiphysis  of  the  fibula  to  the  left  has  appeared,  whereas 
it  is  absent  on  the  right.  This  increase  in  size  of  the  epiphyses  of 
the  left  knee  over  that  in  the  right,  and  the  presence  of  the  epiphy- 
sis of  the  fibula  on  the  left,  are  due  to  the  increased  blood  supply 
occurring  in  the  process  of  a  chronic  infection.  This  picture  also 
shows  lines  radiating  transversely  across  the  lower  diaphysis  of  the 
femur  and  less  marked  in  the  upper  diaphysis  of  the  tibia.  These 
narrow  lines  are  supposed  to  represent  the  old  lines  of  the  epiphyses. 

Knee;  Epiphijseal  Line:  Epiphysitis  and  Osteochondritis. — Plate 
198  illustrates  an  inflammation  of  the  epiphyseal  line  in  the  knee 


THE  EXTREMITIES.  167 

of  a  child  one  year  old.  The  soft  parts  in  this  case  are  normal,  with 
the  exception  perhaps  of  a  slight  amount  of  thickening  around  the 
knee-joint.  The  structure  of  the  femur  is  practically  normal  until 
the  epiphyseal  line  is  reached.  It  is  to  be  noticed  that  the  epiphys- 
eal line  is  darker  than  normal,  showing  new  formation  of  bone.  The 
epiphyses  of  the  tibia  and  fibula  also  show  the  same  characteristic 
increased  deposit  of  lime,  which  points  strongly  to  inflammatory 
proUferation  around  the  epiphyseal  line.  All  the  epiphyses  in  this 
case  also  show  the  same  change  in  the  epiphyseal  lines.  The  con- 
dition is  mostly  one  of  epiphysitis,  but  there  may  also  be  a  certain 
amount  of  osteochondritis. 

Knee;  Tibia:  Old  Trauma,  Suppuration  of  Epiphysis. — Plate 
199  illustrates  the  condition  of  a  tibia  due  to  an  early  trauma  fol- 
lowed by  suppuration  of  the  epiphysis  of  the  tibia.  This  occurred 
in  a  girl  ten  years  old.  The  femur  in  this  case  is  normal  and  its 
epiphyseal  line  is  still  easily  seen  and  shows  no  evidence  of  ossifi- 
cation. Along  the  epiphyseal  line  of  the  tibia,  however,  there  is 
complete  ossification  of  its  epiphysis.  The  fibula  is  seen  to  be  longer 
than  the  tibia,  which  we  would  expect,  as  its  epiphysis  is  still  unossi- 
fied  and  it  has  continued  to  grow,  while  the  tibia  has  ceased  to  grow. 

Knee:  Old  Inflammation — Infectious  Arthritis,  Atrophic  Variety. — 
Plate  200  illustrates  one  of  the  results  of  inflammation  of  the  knee- 
joint  in  a  child  three  years  old.  There  is  marked  thickening  of  the 
soft  parts  around  the  knee-joint  and  a  slight  roughening  of  the 
femoral  epiphysis.  The  shafts  of  the  bones  are  normal,  except  that 
there  is  a  rather  fine  pencilling  at  the  lower  end  of  the  femur  and 
at  the  upper  end  of  the  tibia.  The  plate  illustrates  the  condition 
of  infectious  arthritis  of  the  atrophic  variety. 

Knee:  Inflammatioyi — Villous  Arthritis. — Plate  201  shows  one 
of  the  end  results  following  inflammatory  disturbance  of  the  knee- 
joint.    This  is  the  class  of  cases  which  is  spoken  of  as  villous  arthritis, 


168  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

and  may  arise  from  a  number  of  causes,  or  rather  follow  a  number  of 
processes.  Roentgenographs  of  cases  of  this  kind  have  been  rather 
confusing,  owing  to  the  attempt  of  certain  writers  to  have  this  con- 
dition represent  a  class  rather  than  the  result  of  a  number  of  inflam- 
matory conditions.  The  tissues  around  the  knee-joint  are  seen  to 
be  thickened,  especially  in  the  popliteal  space.  The  capsule  of  the 
joint  is  greath^  thickened  and  can  be  easily  outlined.  The  joint  itself 
is  full  of  a  roughened  villous  hypertrophic  growth.  This  lesion  was 
supposed  to  be  the  result  of  an  acute  septic  infection  of  the  knee, 
accompanied  by  swelling,  heat,  and  pain,  but  the  symptoms  did  not 
subside  under  the  usual  treatment.  Before  operating  the  Roent- 
genograph showed  a  simple  villous  arthritis  and  at  the  operation  no 
infection  was  discovered. 

Knee:  Inflammation,  Ankylosis. — Plate  202  represents  the  end 
results  of  a  severe  case  of  inflammatory  disturbance  of  the  knee- 
joint  not  recognized  in  the  early  stages  and  resulting  in  ankylosis 
of  the  joint  in  a  boy  thirteen  years  old.  The  picture  shows  complete 
ossification  between  the  heads  of  the  femur  and  tibia.  To  be  no- 
ticed is  the  great  change  in  the  structure  of  the  bone  at  the  lower 
end  of  the  femur  and  at  the  upper  end  of  the  tibia,  and  that  a  for- 
mation of  new  bone  extends  directly  across  the  line  of  ossification. 
The  patella  is  seen  to  be  greatly  atrophied  in  quality  rather  than  in 
size,  a  natural  result  arising  from  disuse,  as  the  joint  was  perfectly 
stiff  and  could  not  be  bent. 

Before  speaking  more  in  detail  of  the  infectious  class  of  cases  in 
connection  with  the  joints,  in  other  words,  infectious  arthritis,  a  few 
explanatory  suggestions  ma}^  be  of  use  to  the  student.  Of  especial 
significance  are  the  results  of  Stone's  investigations  of  these  cases 
in  early  life,  since  he  has  had  for  many  j^ears  unusual  opportunities 
for  examining  and  operating  on  infants  and  young  children  at  the 
Infants'  Hospital. 


THE  EXTREMITIES.  169 

He  draws  attention  to  the  anatomical  fact  that  there  is  a  ver\' 
free  vascular  supply  of  the  epiphyseal  lines  by  terminal  arteries  and 
that  this  increases  the  liability  of  infections  reaching  these  points 
through  the  blood.  This,  in  addition  to  the  supposition  that  infec- 
tions entering  through  the  ear,  tonsil,  and  other  sources  attack 
most  readily  those  parts  where  there  is  an  unusual  blood  supph', 
and  where  there  are  tissues  especially  susceptible  to  infection, 
makes  it  highly  probable  that  most  infections  of  the  joints  in  early 
life  begin  in  the  epiphyseal  lines.  The  underlining  cause  of  these 
infections  may  often  be  traced  directly  to  some  preceding  disease 
which  not  only  impairs  the  general  health  but  also  aids  to  bring  the 
infecting  organisms  into  the  circulation.  Thus  in  young  children  it 
is  common  to  see  epiphyseal  lesions  after  pneumonia,  measles,  or 
scarlet  fever.  In  veiy  young  infants  the  unhealed  umbilicus  seems 
to  be  a  not  infrequent  source  of  infection.  The  opportunity  for 
infection  through  the  tonsils  and  lymphoid  tissue  of  the  nasopharynx 
is  generally  recognized.  In  this  way  a  preceding  disease  which  allows 
the  entrance  of  the  organism  into  the  circulation  leads  to  an  infec- 
tion of  a  vascular  area,  the  resistance  of  which  has  been  impaired 
by  perhaps  only  a  slight  trauma.  Since  the  pathologic  process  of 
this  area  may  extend  still  further  and  may  result  in  an  exudate,  it  is 
well  to  study  certain  points  in  connection  with  the  anatomy  of  the 
joints.  In  order  to  understand  rightly  the  picture  of  an  exudate 
in  the  neighborhood  of  a  joint,  it  is  also  important  and  even  neces- 
sary to  bear  in  mind  the  anatomic  relation  of  the  epiphysis  to  the 
capsule  of  the  joint.  When  the  epiphyseal  line  reaches  within  the 
joint-capsule  an  exudation  of  pus  can  reach  the  joint  whenever  the 
epiphj^sis  is  separated  by  suppuration.  In  the  wrist  the  capsule  is 
inserted  into  the  epiphysis  of  the  radius  and  ulna,  and  not  into  the 
sac,  so  that  pus  to  reach  the  joint  has  to  perforate  the  cartilaginous 
epiphysis.    In  the  hip-joint  and  in  the  shoulder-joint  the  epiphyseal 


170  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

line  reaches  within  the  joint-capsule,  and  thus  when  the  epiphysis 
is  separated  by  suppuration  the  pus  can  enter  the  joint.  The  same 
reasoning  is  true  of  the  upper  epiphysis  of  the  tibia,  for  the  capsular 
ligament  of  the  knee  docs  not  cross  the  epiphysis  but  is  inserted  into 
it,  therefore  when  separation  occurs  the  pus  burrows  under  the 
periosteum  but  does  not  break  into  the  knee.  Different  parts  around 
the  knee-joint  may  be  involved  according  to  where  the  pus  has  the 
freest  vent.  Sometimes  the  extension  may  be  into  the  extra-articu- 
lar tissues,  or  up  into  the  shaft  of  the  femur,  or  again  down  into 
the  joint  itself. 

The  point  of  especial  interest  in  regard  to  this  group  of  cases  is 
the  exact  point  of  the  original  focus  of  infection.  At  operation  it  is 
rarely  possible  to  determine  the  location  of  the  original  focus  accu- 
rately. It  seems  probable  that  it  is  usually  either  the  epiphyseal  line 
close  to  the  periosteum,  or  the  periosteum  near  to  the  epiphyseal 
line.    The  reasons  for  this  belief  are: 

This  location  seems  usually  to  be  the  centre  of  the  abscess. 

The  condition  is  brought  on  by  the  same  factors  which  bring  on 
true  epiphysitis,  namely,  slight  trauma  combined  with  the 
presence  of  an  infecting  organism. 

The  early  symptoms  are  identical  with  those  of  acute  epiphysitis. 

These  abscesses  occur  most  frequently  at  the  age  at  which  epiphys- 
eal injuries  are  most  common. 

The  location  of  these  abscesses,  their  course,  their  symptoms,  and 
their  whole  clinical  history  differ  absolutely  from,  those  of 
abscesses  originating  in  lymph-nodes  and  also  from  those 
originating  among  the  muscles  and  fascice. 

On  the  other  hand  Stone  has  never  found  one  of  these  extra- 
articular abscesses  showing  any  erosion  of  the  bones,  though  very 
frequently  the  periosteum  is  slightly  frayed  and  ragged  close  to  the 


THE  EXTREMITIES.  171 

epiphyseal  line,  as  though  it  might  have  been  perforated  at  this 
point.  It  is,  therefore,  probable  that  in  all  these  varieties  of  cases 
there  is  an  infection  beginning  in  or  close  to  the  epiphyseal  line,  and 
that  when  suppuration  occurs  the  pus  spreads  along  the  anatomic 
Unes  of  least  resistance.    These  depend  on : 

The  spot  in  the  epiphyseal  line  at  which  injection  occurs,  which 

is  determined  presumably  by  the  nature  of  the  trauma. 
The  anatomy  of  the  epiphysis. 

If  the  original  focus  of  infection  is  at  the  periphery  of  the  epi- 
physeal line  the  pus  is  ver}^  likely  to  find  a  vent  into  the  surrounding 
tissues  before  any  extensive  damage  is  done  to  the  epiphj^seal  Une 
itself.  On  the  other  hand,  if  the  infection  occurs  at  the  centre  of 
the  epiphyseal  line  the  chance  of  a  complete  separation  and  conse- 
quent necrosis  of  the  whole  epiphysis  is  much  greater.  Thus  the 
entire  question  is  one  of  anatomy. 

The  cases  of  dissecting  periostitis  usuall}^  occur  in  somewhat 
older  children  than  do  the  cases  with  abscesses  in  or  about  the 
joints.  While  some  apparently  start  at  the  epiphyseal  line,  in  other 
cases  the  infection  seems  to  be  primary  under  the  periosteum.  Peri- 
osteal infections  occur  usually  in  the  tibia,  radius,  or  ulna.  They 
are  especially  common  about  the  ankle  and  wrist,  and  somewhat 
less  common  about  the  lower  end  of  the  femur.  It  seems  reasonable 
to  suppose  under  these  circumstances  that  direct  injury  of  exposed 
parts  plays  a  most  important  role  in  the  causation  of  these  lesions. 

In  another  class  of  cases  connected  with  the  periosteum  and  its 
separation  from  the  bone  we  may  have  two  results  which  should  be 
carefully  looked  for  in  our  Roentgen  examination.  For  instance, 
the  bone  may  become  necrotic,  not  as  a  result  of  inflammation 
from  infection  of  the  marrow,  but  as  a  result  of  the  interference 
with  nutrition  incident  to  the  stripping  off  of  the  periosteum  and 


172  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

the  consequent  destruction  of  the  nutrient  vessels.     In  this  case 
there  would  be  necrosis  but  not  osteomyelitis. 

Stone  gives  the  following  varieties  of  lesions  originating  in  the 
epiphyseal  line: 

Acute  epiphysitis  resulting  in  the  sequestration  of  the  epiphysis 
and  incidental  involvement  of  the  joint. 

Acute  epiphysitis  with  perforation  into  the  joint,  residting  in  an 
acute  articidar  abscess. 

Acute  epiphysitis  with  perforation  outside  the  joint  into  the  extra- 
articular tissues  {an  extra-articular  juxta-epiphyseal  abscess). 

Acute  epiphysitis  with  extension  beneath  the  periosteum  (a  dis- 
secting periostitis) . 

In  addition  to  this  a  dissecting  periostitis  is  found  occasionally 
away  from  the  epiphyseal  line  and  without  evident  lesion  in  the 
bone  even  on  careful  search. 

With  this  rather  formidable  array  of  the  different  etiological 
factors  which  may  produce  an  arthritis,  we  should  certainly  appre- 
ciate how  important  it  is  that  aid  in  our  differential  diagnosis  by 
the  Roentgen  ray  should  be  obtained  early.  During  infancy  the 
wide  area  of  cartilage  and  the  vulnerability  of  the  epiphyseal  line 
give  ample  opportunity  for  suppuration  to  spread  outward  rather 
than  to  enter  the  shaft.  As  development  advances,  as  the  cartilage 
at  the  epiphyseal  line  becomes  thinner,  and  as  the  epiphyseal  line 
itself  becomes  less  well  defined,  the  likelihood  of  sepsis  spreading 
into  the  medullaiy  cavity  increases.  Thus  the  infections  involving 
no  other  part  of  the  bone  than  the  epiphyseal  line  are  particularly 
to  be  expected  in  the  j^oungest  patients  and  cannot  possibl}'  occur  in 
adults.  True  osteomyelitis  is  more  common  in  older  children,  and 
any  infection  beginning  in  the  epiphyseal  line  in  adults  must  of 
necessity  be  a  true  osteomyelitis. 


THE  EXTREMITIES.  173 

In  older  children  dissecting  periostitis  is  relatively  common. 
The  pain,  and  especially  the  tenderness  and  swelling  in  such  cases,  is 
usually  more  widely  diffused  than  in  an  acute  osteomyelitis. 

The  value  and  the  limitation  of  Roentgenographs  in  these  cases 
should  be  clearly  understood.  In  those  taken  early  in  the  course  of 
acute  infections  beginning  in  the  epiphyseal  line  in  infants  and 
young  children  there  is  no  reason  to  expect  any  change  from  the 
normal.  In  such  cases  the  disease  involves  the  cartilage,  which 
shows  at  best  but  vaguely  even  in  the  clearest  Roentgenographs. 
The  most  that  can  be  looked  for  is  an  irregularity  of  the  end  of  the 
diaphysis,  or  a  broadening  or  haziness  between  the  epiphysis  and 
diaphysis.  Neither  of  these  points  can  be  determined  accurately  or 
even  approximately  without  wide  experience.  Early  in  the  course 
of  infections  under  the  periosteum  the  Roentgenograph  will  show  no 
change  in  the  bone,  unless  it  is  a  slight  degree  of  roughening  of  the 
outer  part  of  the  cortex.  In  due  time  the  new  forming  periosteal 
bone  may  be  seen  separated  very  slightl)'  from  the  underlying  cor- 
tex. The  negative  value  of  a  good  Roentgenograph,  however,  as 
showing  the  absence  of  any  advanced  lesion  within  the  diaphysis,  is 
often  of  the  utmost  importance  and  should  never  be  disregarded. 

In  connection  with  what  will  be  said  concerning  congenital 
syphilis  it  is  well  to  remember  that  this  may  often  during  infancy 
cause  well-defined  swelling  and  tenderness  at  the  epiphyseal  lines. 
Among  older  children,  of  course,  periosteal  syphilitic  lesions  are 
very  common,  and  indeed  it  has  long  been  noted  that  syphiUtic 
periostitis  is  the  marked  lesion  in  older  children,  while  syphilitic 
osteochondritis  most  commonly  occurs  in  young  infants.  As  a  rule, 
however,  especially  if  the  Roentgen  ray  is  used,  there  is  not  much 
probabiUty  of  the  syphilitic  lesions  being  confused  with  the  acute 
epiph3'seal  or  periosteal  infections. 

In  like  manner  we  should  bear  in  mind  that  the  subperiosteal 


174  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

hemorrhages,  so  commonly  occurring  in  infantile  scorbutus,  at  times 
with  their  extreme  pain  and  tenderness  simulate  closely  pus  in  the 
same  locality,  but  in  this  case  the  general  clinical  symptoms  would 
aid  in  the  differential  diagnosis.  The  symptoms  of  scorbutus  show 
a  slow  onset  and  a  relatively  low  temperature,  in  contrast  with  the 
acute  attacks  of  subperiosteal  effusion  from  other  causes. 

I  believe  that  in  all  these  cases  Roentgenographs  should  be 
taken  from  time  to  time  through  the  course  of  the  disease,  even 
when  the  symptoms  are  mild.  The  profession  wall  gradually  learn 
that  the  physical  examination  of  these  cases  gives  us  infinitely  less 
information  than  does  the  Roentgen.  This  method  of  examination 
is  more  valuable  than  any  other,  whether  it  be  in  cases  of  severe 
infantile  scorbutus,  or  of  osteomyelitis,  infectious  periostitis,  infec- 
tious epiphysitis,  or  infectious  osteochondritis. 

In  regard  to  the  special  organisms  which  give  rise  to  infectious 
arthritis  and  to  osteomyelitis,  we  may  say  that  in  the  chronic  cases 
of  low  grade  we  find  mostly  the  staphylococcus,  while  in  rapidly 
septic  cases  the  streptococcus  is  most  common.  The  pneumo- 
coccus  produces  a  comparatively  chronic,  while  the  bacillus  of 
typhoid  either  an  acute  or  chronic  condition.  We  must  remember 
also  that  the  conditions  in  these  infections,  as  seen  in  children  up 
to  the  age  of  puberty,  are  not  altogether  like  those  of  the  adult,  and 
that  the  characteristic  pictures  seen  in  adults  often  cannot  be  shown 
in  children.  It  should  be  noted  for  the  purpose  of  differential  diag- 
nosis that  clinically  the  characteristic  picture  of  an  acute  poly- 
arthritis may  be  present,  and  yet  it  may  be  verj^  difficult  to  deter- 
Kiine  the  cause  of  the  condition.  The  reason  for  this  is  that  we  at 
times  see  in  the  living  individual  terminal  results  of  an  acute,  sub- 
acute, or  chronic  inflammatory-  process  which  may  be  slightly  active 
or  entirely  quiescent. 

It  is  also  well  to  note  that  we  can  have  a  combination  of  both 


THE  EXTREMITIES.  175 

atrophy  in  quality  and  atrophy  in  size  in  certain  cases  which  show 
simply  a  decrease  in  the  size  of  the  bone  with  an  absorption  of  the 
lime  salts.  This  is  seen  especially  in  the  chronic  forms  of  arthritis 
as  well  as  in  tuberculosis  of  the  bone  or  in  general  tuberculosis.  It 
is  also  seen  in  paralytic  conditions,  such  as  poliomyeUtis  anterior, 
as  already  shown  in  Plate  168;  also  in  some  of  the  malignant  osteo- 
mata,  where  spontaneous  fracture  takes  place,  and  very  rapidly 
extends  in  both  directions,  but  usually  towards  the  origin  of  the 
nutrient  arteries.  Here  we  find  also  a  diminution  in  the  size  of  the 
bone  and  an  actual  absorption  of  the  substance  of  the  bone  with- 
out any  tendency  towards  the  formation  of  a  callus. 

In  connection  with  those  cases  in  which  there  is  an  infection  of 
the  periosteum,  we  should  note  that  in  acute  infections  bj'^  a  pyo- 
genic organism  outside  the  joint-capsule  the  process  may  start  with 
a  direct  infection  of  the  periosteum  or  through  a  roughened  or 
ragged  periosteal  line.  In  the  former  case  we  may  have  the  appear- 
ance in  the  Roentgenograph  of  a  definite  beginning  of  proliferation 

of  the  periosteum. 

EPIPHYSITIS 

Certain  anatomic  facts  are  worthy  of  note  when  we  are  con- 
sidering inflammatory'  conditions  of  the  epiphyses.  There  is  a  very 
marked  difference  between  the  epiphyses  as  they  exist  in  the  joint 
of  a  child  and  in  an  adult.  It  is  very  important  that  by  means  of 
the  Roentgenograph  we  should  not  mistake  a  normal  separation  of 
the  epiphysis  in  a  young  subject  for  a  fracture,  since  the  same  pic- 
ture in  an  adult  would  almost  invariably  represent  the  latter.  It 
is  also  known  that  where  a  dislocation  is  produced  by  trauma  in 
an  adult,  it  is  much  more  likely  in  the  case  of  a  child  to  cause  sepa- 
ration of  the  epiphysis.  It  is  all  the  more  important  to  recognize 
these  injuries  of  the  epiphyses  in  young  subjects  since,  unless  prop- 
erly treated,  they  are  followed  by  suppuration  and  stiffness  in  a 


176  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

neighboring  joint,  resulting  perhaps  in  a  deformity  or  in  an  imper- 
fect development  of  the  limb.  It  is  also  to  be  noted  that  the  epiphy- 
ses of  the  knee,  wrist,  and  shoulder  are  of  especial  importance  so 
far  as  the  increase  in  length  of  the  bones  is  concerned,  because  they 
are  the  last  to  join  the  shaft  and  the  growth  in  them  is  consequently 
continued  the  longest.  The  striking  growth  of  a  small  centre  of 
ossification  in  the  course  of  five  or  six  years  is  quite  remarkable. 
Hammond  has  done  such  excellent  work  regarding  the  epiphyses 
in  this  connection  that  I  shall  quote  from  his  results  quite  freely. 

Shoulder. — In  connection  with  the  epiphyses  of  the  shoulder 
the  upper  epiphysis  of  the  humerus  is  found  as  a  dome-shaped  mass 
which  appears  to  rest  lightlj'  on  top  of  the  shaft.  It  is  composed  of 
the  centres  for  the  head  and  for  the  greater  and  lesser  trochanters, 
which  unite  to  form  this  epiphysis  presumably  at  about  the  fifth 
year,  according  to  the  old  chronologic  method  of  determining  de- 
velopment. The  epiphyseal  line  hes  a  little  way  above  the  surgical 
neck,  and  is  not  horizontal,  but  is  higher  in  the  middle  of  the  shaft 
than  at  the  outer  and  inner  sides.  The  increase  in  length  of  the 
humerus  takes  place  principally  at  this  epiphysis,  and  hence  its  great 
importance. 

Elbow.— The  lower  epiphysis  of  the  humerus  at  the  age  of  five 
or  six  5^ears  shows  merely  a  small,  round,  bony  mass,  the  centre  for 
the  capitellum.  At  twelve  or  thirteen  years,  however,  the  centres 
for  the  trochlea  and  the  external  epicondyle  have  appeared  and  have 
united  with  the  centre  for  the  capitellum,  forming  the  lower  epiphy- 
sis. In  an  anteroposterior  view  of  the  elbow  this  is  seen  as  a  wedge- 
shaped  mass,  its  lower  surface  being  convex,  and  Ijnng  below  the 
external  condyle.  The  internal  epicondj^le  is  not  a  part  of  the  lower 
epiph^'sis  of  the  humerus,  but  is  formed  from  a  separate  centre  of 
ossification.  In  a  Roentgenograph  it  appeal's  as  a  small,  oval  mass 
higher  up  on  the  inner  side  of  the  humerus  and  intimately  con- 


THE  EXTREMITIES.  177 

nected  with  the  internal  condyle.  The  epiphysis  of  the  head  of  the 
radius  is  seen  as  a  small,  flat  disc  lying  just  above  that  bone.  In  a 
lateral  ^^ew  of  the  elbow  at  about  five  years  chronologically  the 
lower  epiphysis  of  the  humerus  appears  to  be  semilunar  in  shape, 
fitting  closely  the  lower  end  of  the  shaft.  The  lower  end  of  the 
humerus  is  bent  forward  so  that  at  times  the  epiphysis  appears  to 
be  slightly  displaced.  The  epiphyseal  line  may  appear  as  a  cleft 
either  at  the  front  or  at  the  back  of  the  humerus,  instead  of  a  uni- 
form line  running  all  the  way  between  the  shaft  and  the  epiphysis. 
This  is  quite  confusing  at  times,  as  the  epiphysis  appears  to  be 
displaced  either  forward  or  backward.  In  these  cases  it  is  only  by 
having  a  Roentgenograph  of  the  normal  joint  that  we  can  deter- 
mine whether  the  epiphysis  is  separated.  It  is  always  well  to  have 
a  Roentgenograph  of  the  normal  joint  in  all  cases,  but  it  is  especially 
necessar}^  in  injuries  to  the  elbow.  The  ray  should  strike  the  part 
at  the  same  angle  in  each  case,  so  that  we  view  both  elbows  as 
nearly  as  possible  under  exactly  the  same  conditions,  otherwise  an 
injured  epiphysis  may  be  overlooked,  or  a  normal  epiphysis  may  be 
mistaken  for  a  separation.  In  the  lateral  view  the  picture  of  the 
internal  epicondyle  is  usually  merged  with  that  of  the  internal 
condyle,  or  may  be  seen  partly  overlapping  it.  The  epiphysis  of  the 
head  of  the  radius  is  seen  above  that  bone,  and  the  epiphysis  of  the 
upper  end  of  the  ulna  lies  above  the  olecranon.  This  latter  epiphy- 
sis is  an  irregular,  rounded  or  three-sided  bony  mass,  and  from  its 
location  and  appearance  is  often  called  the  patella  of  the  arm. 

Wrist. — In  connection  with  the  wrist  it  is  well  to  note  that  the 
epiphysis  of  the  lower  end  of  the  radius  is  sometimes  mistaken  for 
a  Colles's  fracture.  In  an  anteroposterior  view  it  appears  wedge- 
shaped  and  is  thicker  on  the  outer  than  on  the  inner  side  of  the  wrist. 
The  epiphyseal  line,  though  irregular  and  wav)'^,  is  never  rough  and 
jagged  as  in  a  fracture.    Colles's  fracture  also  is  always  found  at  a 

12 


178  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

higher  point  on  the  shaft.  This  epiphysis  has  a  great  share  in  the 
increase  in  length  of  the  radius.  The  epiphysis  of  the  lower  end  of 
the  ulna  is  situated  at  a  slightly  higher  level  than  that  of  the  radius 
and  shows  the  prominence  of  the  styloid  process  on  its  inner  side. 
This  epiphysis,  though  not  commonly  injured,  is  important  because 
the  increase  in  length  of  the  ulna  takes  place  almost  entirely  from  it 
and  any  injurj'  to  this  epiphysis  may  lead  to  serious  deformity  of  the 
forearm,  wrist,  or  hand.  The  epiphyses  of  the  four  inner  metacar- 
pal bones  are  situated  at  the  distal  end  of  the  shafts,  but  in  the 
phalanges  and  in  the  metacarpal  bone  of  the  thumb  (which  latter 
is  to  be  regarded  morphologically  and  developmentally  as  a  pha- 
lanx) the  epiphyses  are  found  at  the  proximal  ends  of  their  respec- 
tive shafts.  In  a  lateral  view  of  the  wrist  the  epiphysis  of  the  ulna 
is  seen  to  be  at  a  distinctly  higher  level  than  that  of  the  radius. 

Hip. — The  epiphysis  of  the  upper  end  of  the  femur  includes 
merely  the  articular  head  of  the  bone  and  forms  no  part  of  the  neck. 
In  a  Roentgenograph  it  sometimes  resembles  in  appearance  the 
epiphysis  of  the  upper  end  of  the  humerus.  Both  the  greater  and 
lesser  trochanters  arise  from  separate  centres  of  ossification,  but 
these  are  less  frequently  shown  in  the  Roentgenograph  than  is  the 
larger  epiphysis. 

Knee. — The  epiphysis  at  the  lower  end  of  the  femur  is  the 
largest  epiphysis  in  the  body,  and  is  probably  the  one  most  fre- 
quently injured.  It  is  the  only  epiphysis  in  which  bone  is  formed 
before  birth.  In  an  anteroposterior  Roentgenograph  it  is  seen  to  be 
a  large,  irregular,  bony  mass,  forming  the  entire  lower  end  of  the 
femur.  The  epiphyseal  line  is  seen  at  the  level  of  the  abductor 
tubercle  on  the  inner  side.  Its  outline  is  wavy,  rises  rather  sharply 
toward  its  centre,  and  has  a  slightly  lower  level  at  the  outer  side  of 
the  bone.  In  this  \'iew  also  are  seen  the  upper  epiphyses  of  the 
tibia  and  fibula.    The  epiphyseal  line  of  the  tibia  somewhat  resembles 


THE  EXTREMITIES.  179 

that  of  the  lower  end  of  the  femur  just  above  it.  The  upper  epiphy- 
sis of  the  fibula  is  a  small  mass  appearing  to  rest  lightly  on  the  top 
of  the  shaft.  In  the  lateral  view  of  the  knee  the  epiphyseal  lines  of 
the  femur  and  fibula  are  nearly  horizontal.  The  epiphysis  of  the 
upper  end  of  the  tibia  in  this  view  is  seen  to  have  a  tongue-like 
projection  extending  down  the  front  of  the  bone  to  the  tubercle  of 
the  tibia.  Sometimes  this  tongue-Uke  process  does  not  reach  so 
far  as  the  tubercle,  and  the  latter  is  seen  developing  from  a  separate 
centre  of  ossification.  Its  importance  has  increased  since  the  Roent- 
gen ray  has  shown  it  to  be  rather  frequently  the  seat  of  injuries 
which  present  somewhat  vague  chnical  signs  and  sjTiiptoms. 

Ankle. — The  lower  epiphyses  of  the  tibia  and  fibula  are  seen 
in  an  anteroposterior  view  of  the  ankle.  The  epiphyseal  line  is 
nearly  horizontal  in  the  case  of  both  bones,  but  that  of  the  fibula  is 
at  a  lower  level  and  comes  opposite  the  ankle-joint.  The  internal 
malleolus  forms  the  inner  portion  of  the  lower  tibial  epiphysis,  and 
the  external  malleolus  is  practically  entirely  composed  of  the  lower 
epiphysis  of  the  fibula.  This  latter  epiphysis  is  greatly  concerned 
in  the  increase  in  length  of  the  fibula. 

Os  Calcis. — The  os  calcis  has  an  epiphysis  on  its  posterior  sur- 
face, just  below  the  attachment  of  the  tendo  Achillis,  and  is  seen  as 
a  small,  oval  disc.  This  is  to  be  remembered  in  studying  Roentgen- 
ographs of  the  foot  in  childhood. 

The  epiphysis  at  the  inner  end  of  the  clavicle,  those  of  the 
acromion  and  coracoid  processes  of  the  scapula,  and  those  of  the 
ribs,  vertebrce,  and  pelvic  bones  are  of  no  practical  importance  and 
would  rarely  cause  confusion  in  studying  a  Roentgenograph. 

Hammond  concludes  his  most  valuable  and  interesting  study 
of  the  normal  epiphyses  by  saying  that  in  injuries  of  the  joints  in 
childhood  the  outhne  at  the  different  stages  of  development  should 
always  be  remembered  and  the  normal  Roentgenographs  should  be 
familiar  to  every  one. 


180  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Young  children,  especially  infants,  are  very  susceptible  to  in- 
flammations in  the  region  of  the  joints  whenever  infection  occurs, 
and  the  younger  the  individual  the  more  apt  is  a  joint  to  be  involved. 
The  small  joints  of  the  wrist,  knee,  and  foot  show  the  greatest  sus- 
ceptibility to  infection.  Pyogenic  organisms  may  enter  at  the 
umbilicus  or  through  the  intestinal  tract  and  give  rise  to  arthritis 
of  the  joints,  as  may  also  the  infecting  organisms  of  influenza,  and 
the  pneumococcus  or  the  gonococcus.  The  infecting  organism  of 
rheumatic  fever  has  a  special  predilection  for  the  joints,  and  the 
bacillus  of  tubercle  finds  a  favorable  site  for  growth  in  the  joints. 
Congenital  sj'philis  very  frequently  attacks  the  joints.  Age  not  only 
makes  a  difference  as  to  the  susceptibility  of  infection  of  the  joints, 
but  it  is  to  be  noted  that  the  tissues  around  the  joints  are  more 
liable  to  infection  in  infants  than  in  older  children.  It  has  also  been 
noted  that  children  under  five  years  of  age  are  much  less  apt  to  have 
suppurative  conditions  in  the  region  of  the  joints.  When  they  occur 
in  children  over  five  years  of  age  the  infection  is  either  tuberculous 
or  rheumatic.  Shortly  after  birth  the  infections  most  frequently 
met  with  are  those  due  to  sepsis,  and  somewhat  later,  though  still 
during  the  early  months,  they  are  due  to  the  gonococcus.  These 
infections  are  apt  to  be  multiple.  To  repeat  somewhat,  the  infec- 
tive agent  may  be  the  streptococcus,  the  staphylococcus,  the  pneu- 
mococcus, the  bacillus  of  typhoid,  the  bacillus  of  influenza,  and 
occasionally  the  colon  bacillus.  In  regard  to  the  infections  which 
involve  the  joints  themselves  certain  infections  of  the  bone  occur 
in  infants  and  young  children,  and  also  in  the  cellular  tissues  adja- 
cent to  the  joints,  which  at  times  give  rise  to  swelling  and  to  those 
symptoms  found  in  actual  involvement  of  the  joint.  Osteomye- 
litis, periostitis,  epiphysitis,  and  deep  cellulitis  may  often  occur 
near  the  joints  and  extend  into  the  joint-capsule.  On  the  other 
hand,  infections  beginning  in  the  joint  may  quickly  involve  the 


THE  EXTREMITIES.  ISl 

tissues  around  the  joint  and  these  may  become  more  inflamed  than 
the  joint  itself.  This  follows  the  rule  of  probable  infection  in  the 
epiphysis  according  as  the  age  of  the  individual  and  the  degree  of 
breadth  of  the  cartilage  of  the  epiphyseal  line  is  greater  or  less. 

If  the  inflammation  is  acute  it  is  somewhat  difficult  to  make 
a  diagnosis,  as  the  local  signs  are  very  similar,  whether  the  infecting 
agent  is  the  streptococcus  or  some  other  organism.  If  the  inflam- 
mation is  of  the  subacute  or  chronic  type  it  is  more  likely  to  be 
due  to  the  bacillus  of  tubercle  or  to  the  gonococcus.  If  the  infec- 
tion involves  only  one  joint,  or  perhaps  shows  moderate  reaction, 
the  probability  is  that  the  organism  is  the  bacillus  of  tubercle. 

It  may  be  said  in  regard  to  the  infection  of  the  hip-joint  that 
Konig's  collection  of  infections  of  this  joint  shows  that  there  were 
560  caused  by  the  bacillus  of  tubercle  and  110  by  other  organisms 
producing  acute  infection. 

The  infection  of  the  epiphyses  represents  a  characteristic  pic- 
ture. The  knee  is  the  most  common  seat  of  the  infection,  but  the 
epiphyses  of  any  of  the  bones  may  be  attacked  and  the  infection 
may  be  single  or  multiple.  The  characteristic  appearance  is  shown 
in  Plate  198.  There  is  swelling  and  thickening  of  the  tissues  around 
the  joint,  and  the  epiphyseal  fine  is  thickened  and  filled  in.  The 
density  is  increased  around  the  epiphysis  and  the  diaphysis.  The 
joint  is  not  involved  early  unless  in  accordance  with  the  normal 
anatomic  relation  of  the  capsules  of  the  joint  as  described  on 
page  169. 

INFECTIOUS  ARTHRITIS 

There  are  a  number  of  inflammatory  conditions  in  the  joints,  in 
many  of  which  the  specific  organism  has  been  discovered.  There 
are,  however,  a  large  number  in  which  the  infecting  organism  has 
not  yet  been  determined,  but  the  process  is  considered  by  analogy 
and  comparison  to  be  caused  by  an  organism.    We  know  that  the 


182  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

bacillus  of  tubercle  is  one  of  the  organisms  which  primarily  attacks 
the  joints.  We  also  know  that  the  various  organisms  which  may 
give  rise  to  the  general  disease  osteomyelitis,  such  as  the  strepto- 
coccus and  staphylococcus,  though  they  primarily  attack  first  the 
shaft  of  the  bone,  yet  often  involve  the  joint.  This  depends  on 
whether  the  capsule  of  the  joint  is  inserted  into  the  epiphysis 
itself  or  into  the  zone  of  proliferation.  .\s  instances  of  other  causes 
of  infectious  arthritis  are  the  pneumococcus,  the  organism  of  rheu- 
matic fever,  the  gonococcus,  and  the  etiologic  factors  of  scarlet 
fever  and  measles.  These  foci  of  infection  may  be  in  any  part  of  the 
body,  as  in  the  tonsil  or  in  the  ear.  The  arthritis  may  be  due  to 
the  presence  of  a  specific  organism  in  the  joint,  or  to  the  action  of 
its  toxins.  In  the  former  case  the  local  process  is  more  severe.  It 
is  thus  seen  that  under  the  general  term  infectious  arthritis  should 
be  included  a  very  large  number  of  diseases.  Arthritis  may  be 
caused  by  a  primary  infection  from  an  original  focus,  or  through 
some  portal  of  entrance,  such  as  the  tonsils,  or  it  may  be  an  accom- 
panying condition  of  certain  general  diseases,  such  as  scarlet  fever, 
typhoid  fever,  syphilis,  epidemic  influenza,  erysipelas,  cerebro- 
spinal meningitis,  gonorrhoea,  glanders,  the  infectious  diarrhoeas, 
and  a  number  of  others.  In  making  a  pathologic  diagnosis  by  the 
Roentgen  ray  in  these  infections  we  should  seek  to  determine  the 
specific  lesions  which  characterize  the  special  disease  and  the  organ- 
ism causing  it.  In  the  past  it  has  been  extremely  difficult  to  accom- 
plish this,  as  the  post-mortem  findings  as  I  have  said  before  almost 
invariably  teach  us  only  terminal  results.  It  is  well  known,  however, 
that  the  same  terminal  results  may  represent  a  number  of  primary 
conditions,  the  lesions  of  which  differ  very  materially  according  to 
the  specific  infecting  organism.  It  will  in  the  future,  therefore,  by 
means  of  the  Roentgen  examination  be  possible  to  determine  during 
life  primar}'  lesions  and  conditions  and  thus  complete  our  knowledge 


THE  EXTREMITIES.  183 

of  the  various  inflammations  of  the  bones  and  of  the  joints.  It  is 
now  prett}'  well  accepted,  from  what  we  have  learned  by  inves- 
tigating diseases  of  the  joints  by  means  of  the  Roentgen  method, 
that  etiologically  they  are  all  infections,  whether  we  have  poly- 
articular disturbance  or  that  of  a  single  joint;  also  that  these  infec- 
tions through  some  direct  portal  or  from  some  definite  focus  are 
transmitted  by  the  blood  usually  to  the  most  highly  organized  ana- 
tomic areas,  and  that  the  infection  takes  place  in  an  especial  tissue, 
according  to  the  predilection  of  the  special  organism  for  that  tissue. 
Of  course  where  the  lesions  are  symmetrical,  we  should  consider 
etiologically  the  possibiUty  of  trophic  conditions.  Infectious  arthri- 
tis, therefore,  may  be  the  result  of  any  of  the  infections  or  pus- 
producing  organisms.  The  severity  of  the  attack  depends  not  upon 
whether  the  joint  is  the  primary  seat  of  the  lesion,  but  upon  the 
special  organism,  and  upon  its  \arulence,  whether  it  is  actually  present 
in  the  joint,  and  also  upon  the  idiosjmcrasy  of  the  indi^^dual  child. 
WTien  we  come  to  consider  the  more  chronic  processes  in  the  joints, 
the  determination  of  a  satisfactory  classification  is  difficult.  From 
what  we  have  learned,  however,  by  studying  these  processes  on  the 
li\'ing  subject  we  are  led  to  believe  that  these  chronic  conditions, 
which  are  when  examined  post  mortem  in  most  cases  terminal 
conditions,  are  produced  by  the  primary'  infection  of  specific  organ- 
isms. This  in  the  future  will  probably  prove  to  be  true  when  it  is 
possible  to  determine  the  especial  infecting  organism.  As  instances 
of  the  chronic  form  of  arthritis,  for  we  can  call  these  also  arthritis, 
since  the  term  infection  impUes  inflammation  and  since  by  this 
term  we  understand  reaction  with  cellular  infiltration,  are  the 
chronic  conditions  represented  by  hypertrophy  and  atrophy  of  the 
tissues  of  the  joints.  The  examination  by  the  Roentgen  method 
will  in  the  future  present  to  us  the  early  lesions  of  these  diseases  in 
the  Uving  subject,  but  it  at  present  merely  shows  that  certain  condi- 


184  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

tions  exist  at  various  stages  of  the  tissue  changes.  Thus  the  Roent- 
genograph can  show  what  in  children  is  a  secondary  condition, 
namely,  a  villous  arthritis.  Again,  the  picture  ma}'  show  a  swelUng 
of  the  soft  tissues  about  the  joint,  or  again  atrophy  of  the  bony 
and  cartilaginous  parts.  It  may  show  hypertrophic  changes  in  the 
bones  and  cartilages  of  the  joints,  Heberden's  nodes,  the  urates  of 
soda,  and  the  deposits  of  gout.  It  is  also  to  be  noticed  that  atrophy 
of  the  surrounding  soft  tissues  as  an  end  result  of  ankylosis  of  the 
joint  commonly  occurs. 

Although  details  of  the  examination  by  the  Roentgen  method 
are  not  by  any  means  completelj'  developed,  or  in  fact  thoroughly 
understood,  still  it  is  well  known  by  expert  Roentgenologists  that 
certain  definite  pathologic  facts  are  being  continually  demon- 
strated in  these  cases.  The  change  which  occurs  in  the  joint  is 
that  of  an  increased  blood  supply.  It  is  demonstrated  in  all  of 
these  cases,  if  seen  early,  that  there  is  an  increase,  usually  in  the 
size  of  the  bone,  as  is  shown  in  the  plate.  If  the  knee-joint  is 
infected  the  condyles  will  be  increased  in  size  in  comparison  wath 
the  opposite  side.  The  epiphysis  of  the  fibula  if  not  already  devel- 
oped will  appear  earlier  than  on  the  unaffected  side,  and  it  is 
e\'ident  that  this  inflammation  is  due  to  a  definite  organism. 

It  is  well  to  again  enunciate  the  importance  of  bearing  in  mind 
that  in  children,  especially  in  young  children,  the  acute  lesion  of  the 
bone  is  usually  at  the  beginning  an  epiphysitis  or  a  periostitis,  and 
not  an  osteomyeUtis,  for  the  bone-marrow  is  not  involved.  The  pus 
ceases  to  spread  in  bone  or  cartilage  when  once  it  has  any  other 
direction  in  which  to  spread,  and  it  ceases  to  dissect  up  the  peri- 
osteum when  it  can  escape  in  any  other  direction.  Hence  in  young 
subjects,  in  contradistinction  from  the  later  periods  of  development, 
the  pus,  having  a  freer  vent  into  the  line  of  the  epiphyseal  cartilage, 
does  not  so  frequently  attack  the  medulla,  bone,  and  periosteum. 


THE  EXTREMITIES.  185 

Humerus:  Infectious  Arthritis,  Atrophy  of  Shaft. — Plate  203  rep- 
resents a  case  of  infectious  arthritis  in  a  child  and  shows  a  marked 
atrophy  of  the  shaft  of  the  humerus,  this  atrophy  being  both  of 
size  and  of  qualit}\  The  outlines  of  the  cortex  and  the  medulla  in 
the  shaft  are  distinctly  marked.  The  special  infecting  organism 
was  not  ascertained  in  this  case.  The  child  according  to  the  ana- 
tomic age  should  be  placed  in  Group  F  or  G. 

Plate  204  represents  the  hands  of  the  same  case.  These  hands 
show  the  finely  pencilled  outlines  of  the  bones.  There  is  no  absolute 
destruction  of  tissue,  but  simply  absorption.  The  joint  substances 
are  not  as  yet  disturbed.  In  the  left  hand  there  is  a  sUght  delay  in 
the  development  of  the  carpal  bones.  There  is  also  a  slight  amount 
of  inflammation  of  the  tissue  in  both  joints. 

Hand:  Infectious  Arthritis. — Plate  205  shows  a  case  of  infectious 
arthritis  with  the  organism  not  determined,  showing  itself  in  the 
hand  of  a  boy  four  and  a  half  years  old.  The  second  and  third 
metacarpal  bones  show  some  thickening  of  the  p)eriosteum  along  the 
shaft.  The  third  metacarpal  bone  also  shows  two  small  areas  of 
absorption  of  the  lime  salts.  There  is  only  a  very  slight  inflam- 
mation of  the  tissues  shown  by  decreased  radiability  in  the  palm 
of  the  hand.  There  is  a  thickening  of  the  tissues  about  the  wrist- 
joint.  The  carpal  bones  are  a  little  larger  than  normal  and  their 
structure  is  somewhat  efifaced. 

The  carpal  bones  are  a  Uttle  larger  than  normal,  show  less 
bony  structure. 

Knee:  Effusion. — Plate  206  shows  a  lateral  view  of  an  effusion 
in  the  knee-joint  of  a  boy  ten  years  old.  There  is  no  disturbance 
of  the  femur,  tibia,  or  fibula,  excepting  in  the  posterior  aspect  of  the 
condyles  of  the  femur,  which  are  a  little  ragged.  The  patella  has  a 
few  excrescences  of  bone  on  its  superior  border.  This  is  probably 
due  to  irregular  ossification.    The  tissues  about  the  joint  seem  to  be 


186  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

thickened  as  well  as  to  contain  fluid.  The  fluid  is  differentiated 
from  the  density  of  the  knee-joint  by  the  ballooning  character  of 
the  density  as  well  as  by  the  space  occupied  by  the  subpatella  fat 
pad,  which  is  absent  in  this  plate.  It  will  be  noticed  that  the  liga- 
mentum  patellae  is  pushed  upwards  and  that  it  is  convex  on  its 
anterior  surface. 

Femur:  Infection  —  Non-tubercular.  —  Plate  207  shows  the  de- 
struction of  the  head  of  the  right  femur  from  some  septic  infection, 
the  specific  organism  of  which  was  not  determined,  but  in  all  proba- 
bility was  not  tubercular. 

Rheumatic  Fever — Knee. — Plate  208  represents  the  left  knee-joint 
of  a  case  of  rheumatic  fever.  In  this  case  there  was  acute  swelling, 
pain,  and  fever,  and  the  Roentgen  plate  taken  early  in  the  attack 
showed  slight  thickening  of  the  capsule.  The  reproduction,  however, 
shows  nothing  abnormal  and  the  illustration  is  merely  given  here  to 
show  how  difficult  it  is  to  detect  in  some  of  the  acute  infections 
of  the  joints  any  pathologic  process  whatever. 

Rheumatic  Fever — Ankle. — Plate  209  shows  the  joint  of  the  ankle 
of  the  same  subject.  Here  also  there  was  sweUing,  tenderness,  and 
fever,  and  the  case  clinically  seemed  to  be  one  of  rheumatic  fever. 
In  this  case  the  Roentgenographic  plate  also  showed  thickening  of 
the  capsule  of  the  joint,  but  here  also  nothing  special  could  be 
detected  in  the  reproduction. 

INFECTIOUS  PERIOSTITIS 

The  diagnosis  of  an  early  infection  of  the  periosteum  by  means 
of  the  Roentgen  ray  is  attained  principally  by  recognizing  certain 
pathologic  changes,  such  as  thickening  and  bulging  of  the  peri- 
osteum. Usually  the  line  of  the  periosteum  is  less  distinctly  seen, 
particularly  that  of  the  normal  bone.  Again  the  periosteum  may 
be  seen  to  be  broken  and  ragged,  exposing  the  cortex. 


THE  EXTREMITIES.  187 

OSTEOMYELITIS 

Although  the  disease  osteomyelitis  has  been  recognized  for  a 
number  of  years,  yet  we  now  have  a  much  more  definite  knowledge 
of  it  than  in  the  past.  We  know  that  it  is  not  caused  by  any  one 
special  organism,  but  that  it  is  a  general  term  which  covers  a  num- 
ber of  specific  infections,  and  simply  means  that,  instead  of  special 
organisms  affecting  the  periosteum,  the  cortex  of  the  bone  and  the 
medullary  cavity  are  also  affected.  Now  that  the  Roentgen  ray  has 
been  brought  to  bear  upon  this  general  class  of  infections,  and  a 
special  study  has  been  made  of  these  different  organisms  in  connec- 
tion with  their  infection  of  the  bones,  a  great  advance  has  been  made 
in  our  knowledge  of  the  living  pathology  of  osteomyelitis.  For  this 
reason  also  the  primary  pathologic  conditions  in  the  bones  in  early 
life  have  become  more  prominent,  as  they  show  at  that  period  the 
actual  pathology,  while  at  a  later  period  the  postmortem  in  many 
cases  only  shows  terminal  results.  These  terminal  results  may  some- 
times be  characteristic  of  the  special  infection,  but  more  often  may 
represent  conditions  which  are  the  result  of  a  number  of  entirely 
different  infectious  organisms. 

The  type  of  infections  which  are  grouped  under  the  name  osteo- 
myelitis makes  it  in  some  respects  the  most  important  disease 
of  the  bones  which  occurs  in  early  life.  This  is  true  on  account 
of  the  tremendous  destruction  of  bone  which  may  occur,  either 
terminating  in  death  or  in  various  degrees  of  deformity  which 
may  be  permanent.  The  rapidity  of  the  onset  and  the  resulting 
rapid  destruction  of  the  bone  give  osteomyelitis  a  place  in  dis- 
eases of  the  bone  which  appendicitis  holds  in  diseases  of  the 
abdomen.  In  the  case  of  appendicitis  delays  in  operation  may 
mean  death.  In  osteomyelitis,  delay  in  diagnosis  and  in  operative 
treatment  may  mean  not  only  death,  but  resulting  deformities 
which  cannot  be  rectified,  and  in  some  cases  may  mean  more  than 


188  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

death.  It  is  therefore  important  that  an  early  diagnosis  should  be 
made  of  this  class  of  cases,  and  that  operative  treatment  if  indicated 
should  be  decided  upon  at  once.  To  accomplish  this  early  diagnosis, 
the  Roentgen  ray  is  of  inestimable  value,  for  at  times  it  tells  us  what 
the  clinical  examination  fails  to  find. 

Osteomyelitis  is  a  general  disease  so  far  as  its  etiology  is  con- 
cerned, but  in  many  cases  it  can  only  be  diagnosticated  surely  by 
the  Roentgen  ray.  Among  the  numerous  organisms  which  may 
cause  it,  the  most  prominent  is  the  staphylococcus  in  the  chronic 
cases  of  low  grade,  while  in  rapidly  septic  cases  the  streptococcus  is 
most  commonly  found.  In  certain  cases  the  pneumococcus  occurs 
and  produces  a  fairly  chronic  condition,  and  finally  the  bacillus  of 
typhoid  may  cause  either  an  acute  or  chronic  process. 

I  shall  merely  enunciate  the  fact  that  the  Roentgen  ray  should 
be  used  at  once  during  the  earUest  period  of  the  symptoms,  and  that 
we  should  not  be  led  astray  in  our  diagnosis  by  thinking  that  the 
case  may  be  one  of  rheumatic  fever.  There  is  more  confusion  in  the 
mind  of  the  general  practitioner  in  regard  to  rheumatic  fever  in  con- 
nection with  this  set  of  cases  than  arises  when  a  difTerential  diagnosis 
is  to  be  made  from  any  other  disease.  For  this  reason  the  organism 
which  may  be  producing  an  osteomyelitis  has  an  opportunity  to 
thoroughly  infect  the  bone,  and  often  to  such  an  extent  that  opera- 
tive treatment  becomes  of  little  avail.  This  is  especially  the  case  in 
very  young  children,  where  the  percentage  of  cases  caused  by  infec- 
tions of  the  epiphyses  is  very  great. 

As  in  other  severe  diseases  of  the  bone,  it  is  difficult  to  make  a 
definite  diagnosis  of  osteomyelitis  unless  the  case  is  examined  by 
the  Roentgen  method.  WTien  the  Roentgenograph  is  used,  how- 
ever, the  difficulty  is  very  greatly  lessened. 

Infectious  osteomyehtis  may  be  single  or  multiple  in  its  first 
appearance,  and  in  its  course  may  be  acute,  subacute,  or  chronic. 


THE  EXTREMITIES.  189 

An  involvement  of  any  of  the  bones  may  occur,  but  the  knee  is  the 
most  common  seat  of  infection.  The  tissues  usually  show  swelling 
and  thickening,  the  epiphyseal  line  is  thickened  and  filled  in,  and 
the  radiability  surrounding  the  epiphysis  and  diaphysis  is  increased. 
The  infection  commonly  attacks  the  long  bones,  and  it  is  usually  the 
extremities  of  the  bones  which  are  involved.  According  to  the  site 
of  the  infection  and  of  the  tissues  involved,  the  primary  infection  may 
be  of  the  periosteum  or  of  the  marrow.  When  the  infection  is  seen 
early  by  the  Roentgen  ray  the  principal  pathologic  change  is  found 
in  the  periosteum.  The  change  consists  of  thickening  and  hyper- 
trophy of  the  periosteum  with  its  line  less  distinctly  seen.  Again 
the  periosteum  may  be  thickened  and  ragged,  exposing  the  cortex. 
When  the  infection  is  of  the  marrow  the  Roentgenograph  shows 
very  early  in  the  process  the  infected  area  to  be  represented  by 
one  or  more  definite  degrees  of  density,  varying  in  size  from  a  pin- 
head  to  several  times  that  size.  There  is  also  found,  at  times,  an 
increased  area  of  radiability  in  which  the  structure  of  the  bone 
is  being  destroyed  and  absorption  of  the  lime  salts  is  probably 
taking  place. 

Osteomyelitis,  as  distinctive  from  tuberculosis  or  syphilis  of  the 
bone,  is  shown  by  a  more  definite  proliferation  of  the  periosteum,  a 
more  definite  formation  of  new  bone  in  the  area  of  necrosis,  or  this 
area  may  show  large  pieces  of  bone  which  have  not  been  absorbed. 

In  the  subacute  and  chronic  cases  of  osteomyelitis  the  struc- 
ture of  the  bone  shows  less  distinctly  and  is  accompanied  by  atrophy 
below  the  point  of  infection.  This  atrophy  is  not  particularly  in 
size,  but  rather  in  quality,  and  is  accompanied  by  an  excessive 
amount  of  proliferation  of  the  periosteum.  At  times  the  process 
goes  so  far,  as  is  shown  in  Plate  210,  Fig.  2,  that  there  is  a  definite 
area  of  exposed  bone  surrounded  by  an  involucrum. 

Tibia:  Early  Stage. — Plate  210,  Fig.  1,  represents  the  knee  of  a 


190  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

child  nine  years  old,  showing  one  of  the  earliest  manifestations  of 
osteomyelitis.  The  child  was  kicked  on  the  tibia,  the  injury  having 
taken  place  two  days  before  being  seen.  The  Roentgenograph  was 
taken  on  the  third  day  and  showed  an  increased  radiability  of  bone 
about  one  inch  below  the  epiphyseal  line  of  the  tibia.  Below  this 
there  was  a  slightly  boggy  periosteum  running  down  almost  the  whole 
length  of  the  tibia,  especially  in  front,  and  showing  evidently  an  ex- 
udation of  fluid  under  the  periosteum,  proved  later  by  operation 
not  to  be  blood.  The  clinical  symptoms  were  extreme  pain,  swelling, 
no  fluctuation  or  redness,  tenderness,  and  a  varying  temperature. 

Tibia:  Same  Case,  Later  Stage. — Plate  210,  Fig.  2,  shows  a  later 
stage  of  the  same  case.  Owing  to  a  delay  in  making  a  correct  diag- 
nosis, an  operation  was  postponed  until  infection  had  taken  place, 
and  the  process  went  on  to  such  an  extent  that  the  whole  bone 
became  involved.  The  plate  shows  proliferation  of  the  periosteum, 
with  formation  of  sequestra. 

This  case  was  evidently  one  of  simple  trauma  in  the  beginning, 
and  if  it  had  been  recognized  that  an  early  infection  had  taken  place 
operative  treatment  would  have  been  very  simple  and  would  have 
preserved  the  leg  from  the  extensive  lesions  shown  in  the  Roent- 
genograph. 

Femur. — Plate  211  represents  the  leg  of  a  child  ten  years  old  who 
entered  the  hospital  for  rheumatic  fever.  The  clinical  symptoms 
were  referred  to  the  knee,  where  there  was  swelling  and  tenderness, 
but  nothing  localized  was  detected  in  the  lower  part  of  the  femur. 
The  Roentgenograph  showed  increased  radiability  of  the  diaphysis 
of  the  femur  with  proliferation  of  the  periosteum.  The  operation 
was  delayed  too  long  and  the  infection  went  so  far  that  the  disease 
lasted  for  over  a  year.  Several  operations  had  to  be  performed  for 
the  removal  of  the  sequestra,  and  although  the  child  finally  recov- 
ered it  was  left  with  irreparable  deformity. 


THE  EXTREMITIES.  191 

Femur. — Plate  212,  Fig.  1,  is  the  picture  of  a  child  twelve  years 
old.  The  Roentgenograph  of  this  case  shows  the  permanent  results  of 
acute  osteomyelitis  of  the  left  femur.  It  was  treated  for  tuberculosis 
of  the  hip.  All  of  the  destruction  took  place  within  two  or  three 
months.  An  early  operation  would  have  obviated  this  result.  In  the 
course  of  the  differential  diagnosis  the  process  was  aspirated  and  the 
infection  was  proved  to  be  from  the  staphylococcus. 

Hi]p. — Fig.  2  is  the  picture  of  a  child  five  years  old.  There  was 
a  history  of  swelling  in  the  region  of  the  right  hip  with  sUght  limita- 
tion of  motion  and  pain  about  the  hip.  It  was  sent  to  the  hospital 
with  a  diagnosis  of  tuberculosis  of  the  hip.  The  Roentgenograph 
showed  an  infiltration,  with  the  formation  of  an  abscess  resulting  from 
infection  of  the  neck  of  the  femur.  There  was  proliferation  of  the 
periosteum  about  midway  between  the  greater  and  lesser  trochanter 
and  epiphyseal  line.  There  was  here  also  an  area  of  increased  radia- 
bility.  The  infection  was  so  completely  outside  of  the  capsule  of  the 
joint  that  the  case  was  evidently  not  one  of  tuberculosis  but  of 
osteomyehtis. 

Tibia. — Plate  213,  Fig.  1,  represents  a  case  of  osteomyelitis  of  the 
tibia  in  a  boy  eight  years  old.  In  this  picture  it  will  be  seen  that 
the  capsule  and  soft  parts  about  the  right  knee  are  thickened.  The 
femur  is  comparatively  normal,  as  is  also  the  fibula,  but  at  the  upper 
end  of  the  tibia  there  is  seen  to  be  an  area  of  destruction  of  the  bone 
with  a  formation  of  sequestrum.  The  epiphyseal  line,  as  well  as  the 
epiphysis,  is  involved  in  the  destructive  process,  which  starts  in  the 
epiphyseal  line  of  the  tibia.  Operation  was  delayed  and  the  process 
extended  into  the  epiphysis.  This  case  shows  how  important  it  is 
to  recognize  the  very  early  lesions  of  an  osteomyelitis.  This  could 
have  been  done  if  the  Roentgen  method  of  examination  had  been 
employed  at  once. 

Tibia:  Bone  Plug. — Fig.  2  shows  the  same  case.     An  operation 


192  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

was  performed  later  and  a  bone  plug  inserted  in  the  caAnt.y.  The 
Roentgenograph  illustrates  that  the  operation  must  necessarily  be  a 
failure  for  there  is  a  sequestrum  still  remaining  in  the  cavity.  The 
tibia  shows  below  the  point  simply  absorption  of  the  lime  salts, 
which  is  also  seen  in  the  fibula,  in  both  cases  there  being  a  lessened 
radiability.  This  Roentgenograph  is  a  striking  illustration  of  the 
great  use  of  the  ray,  not  only  in  detecting  the  nidus  of  the  disease, 
and  its  early  portrayal  of  destruction  of  the  tissues,  but  also  how 
a  series  of  pictures  will  aid  the  surgeon  by  elucidating  why  his 
operation  is  a  failure. 

Femur. — Plate  214  represents  a  case  of  acute  infectious  osteo- 
myelitis in  a  girl  two  and  a  half  years  old,  twelve  hours  after  the 
onset  of  the  first  sjonptoms.  There  is  a  haziness  of  the  outline  of 
the  right  femur  with  marked  inflammatory  reaction  of  the  soft  parts 
about  the  thigh.  The  process  went  on,  as  is  shown  in  Plate  215,  to 
a  general  destruction  of  the  entire  shaft  of  the  femur.  This  plate 
illustrates  how  early  changes  in  the  tissues  and  bones  can  be  dem- 
onstrated by  the  Roentgen  ray. 

Femur:  Plate  215  shows  the  same  case  as  Plate  214,  but  five 
weeks  later.  In  the  middle  of  the  shaft  is  an  area  of  inflammation; 
somewhat  lower,  and  on  the  outer  edge  of  the  bone,  there  is  newly 
formed  periosteal  tissue.  Further  down  in  the  upper  part  of  the 
diaphysis  is  the  point  of  attachment  of  the  capsule  and  periosteum 
to  the  shaft  of  the  femur.  It  is  to  be  noticed  that  the  joints  have 
not  yet  become  infected,  but  that  the  infection  of  the  bone  is  con- 
fined within  the  limits  of  the  periosteum.  There  was  a  considerable 
reaction  of  the  soft  parts  not  shown  in  this  plate  but  clearly  seen 
in  the  original  plate.  All  the  other  bones  shown  in  the  picture  are 
normal. 

Elbow. — Plate  216  is  the  picture  of  a  boy  nine  years  old,  with 
osteomyelitis  of  the  elbow.     There  is  seen  to  be  marked  atrophy 


THE  EXTREMITIES.  193 

in  the  quality  of  the  bones,  but  not  in  the  size.  The  epiphyses  of 
all  the  bones  in  the  elbow,  but  especially  of  the  radius  and  of  the 
ulna,  are  almost  completely  eroded  and  the  joint  is  filled  with 
necrotic  material. 

Humeri. — Plate  217  shows  marked  destruction  of  both  humeri 
in  a  boy  eight  years  old.  The  whole  structure  of  the  bone  and  peri- 
osteum of  the  upper  half  of  both  bones  is  seen  to  be  markedly  in- 
volved. There  is  active  destruction  with  formation  of  sequestra  at 
both  upper  ends.  The  joints  of  both  shoulders  are  affected.  The 
head  of  the  bone  on  the  right  is  more  involved  than  on  the  left.  The 
lower  ends  of  the  humeri  on  both  sides  show  a  marked  increase  in 
radiability.  The  thorax  is  normal.  The  infecting  organism  was 
found  to  be  the  bacillus  of  typhoid. 

Radius. — Plate  218  represents  an  osteomyelitis  of  the  lower 
third  of  the  radius  in  a  boy  six  years  old.  The  soft  tissues  are  greatly 
thickened.  There  is  marked  thickening  of  the  periosteum  on  the 
lower  half  of  the  radius,  with  a  general  necrosis  of  the  bone  in  the 
lower  third,  and  with  the  formation  of  a  sequestrum  at  both  points. 
There  is  an  almost  complete  separation  at  the  lower  end  of  the 
radius.  The  epiphyseal  line  is  involved  and  the  proximal  surface  of 
the  epiphysis  is  roughened. 

Radius. — Plate  219,  Fig.  1,  represents  the  photograph  of  a  child 
with  acute  osteomyelitis  of  the  radius.  There  is  seen  to  be  a  con- 
siderable swelling  of  the  soft  parts  of  the  wrist  and  of  the  whole 
lower  arm,  starting  at  the  bend  of  the  elbow. 

The  Roentgenographs,  Figs.  2  and  3,  do  not  show  periosteal 
reaction  on  account  of  the  destruction  of  the  bone.  The  lower  two- 
thirds  of  the  radius  seems  to  be  almost  completely  a  mass  of  necrotic 
material.  The  upper  part  of  the  radius  seems  to  be  out  of  place. 
The  surface  of  the  joint  of  the  elbow  is  apparently  not  infected. 
The  two  carpal  bones  that  are  present  are  not  involved. 

13 


194  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Hiy. — Plate  220  shows  an  acute  infectious  arthritis  in  a  child 
two  and  a  half  years  old.  The  soft  tissues  around  the  left  hip  are 
seen  to  have  a  greater  density  than  on  the  right.  The  shaft  of  the 
femur  shows  slightly  increased  radiability,  and  the  radiability  of 
the  epiphj^sis  is  also  marked.  The  primary  focus  of  the  disease  in 
this  case  is  in  the  acetabulum,  where  at  the  junction  of  the  ischium 
and  ilium  there  is  a  marked  destruction.  There  is  a  small  formation 
of  sequestrum  at  this  point. 

Hij). — Plate  221  shows  a  marked  increase  in  the  radiability  of 
the  soft  tissues  around  the  hip-joint  in  a  boy  seven  years  old.  The 
epiphysis  of  the  greater  trochanter  is  irregular  and  partly  absorbed. 
The  medullar}'  canal  at  the  upper  end  of  the  femur  shows  marked 
absorption  of  lime  salts;  periosteal  reaction  and  proliferation  are 
strongly  marked.  The  epiphyseal  line  is  seen  to  be  very  ragged, 
although  there  is  no  actual  destruction  at  this  point.  The  lower 
portion  of  the  acetabulum  is  also  roughened. 

Femur. — Plate  222  represents  the  results  of  an  infectious  osteo- 
myelitis of  the  upper  part  of  the  femur,  occurring  in  a  girl  three 
and  a  half  years  old  and  produced  by  the  pneumococcus.  The  soft 
tissues  appear  to  be  rather  hazy,  but  of  increased  radiability,  and 
indicate  an  inflammatorj^  action.  Just  outside  the  capsule  of  the 
joint  and  in  the  region  of  the  surgical  neck  of  the  femur  there  is 
seen  to  be  an  area  of  destruction  of  bone  with  the  formation  of  a 
sequestrum.  The  line  of  demarcation  at  the  lower  end  of  the  in- 
volved area  is  clearly  outlined.  There  is  a  slight  increase  of  peri- 
osteum along  the  upper  line  of  the  femur.  The  head  of  the  femur 
and  the  acetabulum  are  perfectly  normal.  No  apparent  decrease  in 
the  lime  salts  is  shown. 

Femur. — Plate  223  shows  a  marked  disturbance  in  the  neck  of 
the  femur  in  a  girl  four  and  a  half  years  old.  There  is  an  almost 
complete  absorption  of  Ume  in  this  area  and  marked  periosteal 


THE  EXTREMITIES.  195 

thickening  at  the  upper  end  of  the  femur  on  both  sides.  There  is 
apparently  no  involvement  of  the  epiphyseal  line,  but  there  is  a 
marked  inflammatory'  reaction  of  the  soft  parts  around  the  greater 
trochanter.    This  infection  was  due  to  the  staphylococcus. 

Hip-joint. — Plate  224  shows  a  mixed  infection  of  the  hip-joint 
in  a  girl  six  years  old.  The  soft  parts  around  the  right  hip-joint  are 
seen  to  be  greatly  thickened  and  the  density  is  much  increased. 
The  shaft  of  the  femur  shows  no  atrophy  of  size,  but  a  slight  one  of 
quality.  The  neck  and  epiphysis  of  the  femur,  however,  are  almost 
completely  destroyed  or  absorbed.  The  acetabulum  also  is  mark- 
edly affected.  There  is  thickening  of  the  periosteum  along  the 
iliopectineal  line.  The  rami  of  the  os  pubis  and  ischium  show  the 
same  process.    There  is  a  partial  dislocation. 

Tibia. — Plate  225  represents  osteomyelitis  of  the  lower  end  of 
the  tibia  in  a  boy  twelve  years  old.  It  is  to  be  noted  that  there  is 
an  area  of  necrotic  bone  which  is  surrounded  by  a  dense  zone  of  new 
bone  formation  which  walls  the  process  completely  off.  This  Roent- 
genograph illustrates  the  condition  which  occurs  in  a  low  grade  of 
staphylococcus  infection. 

Femur. — Plate  226  is  the  picture  of  a  boy  seven  years  old  with 
osteomyelitis  of  the  right  femur.  To  be  noted  is  the  slight  amount 
of  swelhng  in  the  soft  parts  around  the  right  knee-joint.  The  lower 
end  of  the  femur  is  larger  in  size  than  the  left  femur,  and  shows  along 
its  inner  edge  an  absorption  of  Ume  salts.  There  is  h}'pertrophy  in 
addition  to  absorption.  The  epiphysis  of  the  right  femur  shows 
an  irregular  deposit  characterized  by  its  ragged  appearance.  The 
primary  focus  of  the  infection  is  seemingly  in  this  epiphysis. 

Tibia. — Plate  227  represents  osteomyelitis  of  the  left  tibia  at 
its  upper  end  in  a  boy  twelve  years  old.  Th^  picture  shows  a  marked 
proliferation  of  the  periosteum  of  the  upper  third  of  the  tibia,  with 
numerous  sequestra.  An  operation  showed  this  to  be  a  staphy- 
lococcus infection. 


196  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Tibia:  Early  Stage  of  Injection. — Plate  228  shows  a  practically 
normal  tibia  and  foot  except  at  one  point  in  a  boy  twelve  years  old. 
At  the  lower  end  of  the  tibia  close  to  its  epiphyseal  line  there  is  a 
small  area  with  increased  radiability.  This  condition  shows  an  early 
stage  of  osteomyelitis. 

Fibula. — Plate  229  is  the  picture  of  a  girl  eleven  years  old  with 
osteomyelitis  of  the  fibula.  It  will  be  seen  that  the  periosteum  of 
the  fibula  is  greatly  thickened  and  that  in  the  lower  third  there  is 
also  quite  an  area  of  increased  radiabiUty,  which  is  the  focus  of  the 
infection.  It  will  also  be  seen  that  there  is  a  beginning  rim  of  new 
formation  of  bone  around  this  area,  nature's  process  of  walling  off. 
The  other  bones  in  this  picture  are  normal. 

Tibia. — Plate  230  shows  an  undetermined  infection  of  the 
lower  epiphysis  of  the  tibia  in  a  boy  ten  years  old.  The  structure 
of  the  bone  is  perfectl)'  normal  except  at  the  point  of  infection. 
At  this  point  in  the  epiphysis  of  the  tibia  there  is  a  small  area  of 
increased  radiability.  As  j'et  there  is  no  atrophy  of  any  of  the 
bones  of  the  foot. 

Tibia. — Plate  231  shows  a  case  of  chronic  infectious  osteo- 
myelitis in  a  boy  six  years  old.  The  soft  tissues  around  the  knee- 
joint  are  shown  to  be  greatly  thickened.  The  epiphyseal  line  of  the 
tibia  is  ragged  and  irregular  with  some  increase  in  radiability.  Along 
the  inner  margin  of  the  upper  end  of  the  tibia  there  is  a  beginning 
destruction  of  the  bone.  The  femur  and  fibula  simply  show  slight 
increased  radiability. 

HYPERTROPHIC  AND  ATROPHIC  PROCESSES  OF  THE  JOINTS 

The  chronic  hypertrophic  conditions  of  the  joints  which  occur 
in  later  life  are  very  rare  in  early  life.  The  pathologic  condition 
which  is  most  common  in  this  chronic  class  of  cases  in  early  life  is 
represented  by  an  atrophic  condition  of  the  joints.  It  is  a  slow, 
progressive  disease,  and  most  commonly  manifests  itself  in  some  of 


THE  EXTREMITIES.  197 

the  smaller  joints,  usually  in  the  proximal  row  of  the  phalangeal 
articulations.  At  first  one  or  more  joints  are  affected,  but  grad- 
ually other  joints  become  involved  until  in  many  instances  every 
joint  of  the  body  is  included  in  the  destructive  process.  The  prog- 
ress of  the  disease  lasts  for  a  period  of  years.  A  great  deal  of  work 
has  been  done  by  different  investigators  on  this  subject,  but  I  shall 
not  attempt  to  discuss  the  subject  of  classification  here,  as  we  are 
simpl}'  interested  in  what  we  may  expect  to  see  in  the  Roentgeno- 
graphs of  these  cases. 

The  chronic  atrophic  cases  show  a  swelling  of  the  soft  tissues 
about  the  joints  due  to  synovial  fluid,  and  subsequent  atrophy  of 
the  cartilaginous  parts  of  the  bones.  The  Roentgen  ray  is  especially 
valuable  in  these  cases  for  the  purpose  of  differentiating  them  from 
certain  forms  of  infectious  arthritis,  where  there  are  spindle-cell 
swellings  but  where  the  ray  shows  there  is  not  the  characteristic 
atrophy. 

Chronic  Atrophic  Wrists,  Hands,  Arms,  Knees,  Legs,  and  Ankles. 
— Plate  232  represents  the  hands  of  a  boy,  showing  a  chi'onic 
atrophic  condition  of  the  joints  of  the  wrists  and  hands.  There 
is  marked  atrophy  of  the  forearm,  with  considerable  fusiform  swell- 
ing in  the  carpal  region  as  well  as  in  the  third  and  fourth  fingers 
of  the  right  hand  and  the  first,  second,  third,  and  probably  the 
fourth  of  the  left  hand.  Clinically  this  was  a  case  of  infectious 
arthritis  followed  by  atrophy. 

Plate  233  shows  the  knees  of  a  boy  eight  years  old.  There  is 
marked  thickening  about  the  knee-joint,  contrasting  with  the  extreme 
atrophy  of  the  leg.  The  same  condition  of  the  knee-joint  will  be 
noticed  in  the  Roentgenograph;  all  the  bones  of  the  body  were 
affected  in  a  similar  way. 

Knee:  Chronic  Atrophy. — Plate  234  shows  a  Roentgenograph 
of  the  same  boy.     It  is  to  be  noted  that  the  bone  substance  is  more 


198  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

compact  and  smaller  than  normal,  and  that  there  is  an  atrophy  of 
the  substance  of  the  muscles.  The  joint  itself  is  partly  involved 
and  the  surfaces  of  the  joint  are  seen  to  be  greatly  roughened,  espe- 
cially the  epiphysis  of  the  femur.  The  cortex  is  very  sharply  de- 
fined. The  patella  shows  an  atrophic  condition  with  increased 
radiability.  The  outline  of  the  articular  surface  of  the  condyles  is 
irregular,  and  is  due  in  part  to  the  irregular  ossification  of  the  sub- 
stance of  the  bone,  as  well  as  to  some  disease,  as  shown  by  erosion. 
There  is  also  thickening  about  the  joint  but  no  fluid.  There  is 
marked  atrophy  of  the  femur,  tibia,  and  fibula,  not  only  of  size  but 
also  of  quality,  and  characterized  by  finely  pencilled  cortical  bone 
seen  in  all  the  bones.  There  is  a  sharp  outline  of  the  condyles  and  of 
the  epiphysis  of  the  tibia.  There  is  fine  trabeculation  of  the  bone, 
and  the  patella  shows  fine  pencilling. 

SYPHILIS 

The  lesions  of  syphilis  which  can  be  shown  in  Roentgenographs 
are  mostly  of  the  osseous  tissues.  Although  all  the  organs  of  the 
body  may  be  affected  by  the  Spirochseta  pallida,  yet  the  special 
lesions  by  which  the  diagnosis  of  the  disease  can  be  made  when  the 
Roentgen  method  is  employed  are  essentially  those  of  the  bones. 
The  Hving  pathology  of  the  lesions  of  the  bones  differs  according  to 
whether  we  are  dealing  with  a  case  of  congenital  syphilis,  which 
corresponds  to  the  secondary  symptoms  of  acquired  syphilis,  or  with 
the  retarded  and  later  form  of  syphilis  in  childhood,  which  corre- 
sponds to  the  tertiary  lesions  of  acquired  syphilis.  In  the  former  case, 
the  congenital,  we  find  that  the  Roentgenograph  shows  the  picture 
of  an  acute  epiphysitis  and  its  accompanying  periostitis,  leading 
later  to  separation  of  the  epiphyses  and  to  pseudoparalysis,  simu- 
lating also  in  many  cases  fracture.  To  those  who  are  not  especially 
acquainted  with  the  many  ways  in  which  syphilis  simulates  other 
diseases,  these  lesions  of  the  bones  are  apt  to  be  misleading.    I  have 


THE  EXTREMITIES.  199 

seen  cases  where  a  separation  of  the  epiphysis  of  the  wrist  in  young 
infants  has  been  mistaken  and  treated  for  a  fracture,  the  thickened 
periosteum  being  mistaken  for  a  callus.  In  such  cases  as  these 
the  Roentgen  method  aids  us  to  make  a  differential  diagnosis.  The 
lesions  which  are  mostly  to  be  confounded  with  syphiUs  of  the 
bones  are  those  of  tuberculosis.  It  is  in  these  cases  which  are  often 
obscure  that  special  means  for  a  differential  diagnosis  should  be 
employed.  By  means  of  the  Roentgenograph  we  can  distinguish 
the  destruction  of  the  cortex  of  the  bone  and  the  primary  lesions 
occurring  in  the  joint  in  tuberculosis  from  the  marked  thicken- 
ing of  the  periosteum,  layer  on  layer,  significant  of  syphilis. 

In  syphilitic  lesions  of  the  osseous  system  which  occur  in  children 
there  are  at  first  disturbances  of  the  periosteum  with  marked  perios- 
teal overgrowth  and  much  laying  down  of  new  bone.  Usually 
changes  in  shape  occur  more  along  the  middle  of  the  shaft  of  the 
bone  than  near  the  epiphyses.  The  overgrowth  of  periosteum  is 
out  of  all  proportion  to  what  would  be  expected  from  simple  perios- 
titis, or  without  any  change  in  the  bone  excepting  an  increase  of 
the  cortex. 

The  close  simulation  of  syphilitic  dactylitis  and  tubercular 
dactylitis  makes  the  Roentgen  method  of  especial  value  in  the 
differential  diagnosis  of  the  two  diseases.  Plate  237  shows  a  syphi- 
litic dactylitis  with  its  periosteal  lesion,  and  Plate  242  represents  a 
tubercular  dactylitis  with  its  special  destruction  of  bone. 

Syphilitic  Dactylitis. — The  differential  diagnosis  by  the  Roent- 
gen method  shows  that  in  syphilis  there  is  a  definite  change  in  the 
exterior  of  the  bone  without  any  change  in  the  interior  unless 
suppuration  has  taken  place.  The  periosteum  is  thickened  and 
increased  in  size,  so  that  we  may  have  in  a  phalanx  the  character- 
istic changes  that  take  place  in  the  long  bones. 

Cases  have  been  seen  where  the  condition  of  one  hand  was  that 


200  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

of  a  syphilitic  dactylitis  and  of  the  other  hand  that  of  a  tubercular 
dactyhtis. 

The  point  of  diagnosis  generally  in  favor  of  syphilitic  dacty- 
litis and  against  tubercular  dactylitis  is  that  the  long  bones  in 
other  parts  of  the  body  do  not  show  in  tubercular  dactylitis  dis- 
turbances such  as  are  expected  to  be  found  in  retarded  or  congenital 
syphilis. 

Elbow. — Plate  235  represents  syphilis  in  the  elbow  of  a  child 
eleven  years  old.  The  lower  end  of  the  humerus  along  its  inner 
border  shows  great  thickening  of  the  periosteum  due  to  syphilis 
(overgrowth),  and  it  is  to  be  noted  that  there  is  no  change  in  the 
shaft  of  the  bone  with  this  exception.  There  is  no  change  in  the 
soft  tissues. 

Elbow. — Plate  236,  Fig.  1,  represents  a  syphilitic  elbow  in  a  girl 
two  and  a  half  years  old.  There  is  increased  thickening  of  the  perios- 
teum along  the  inner  border  of  the  humerus.  There  is  some  decrease 
in  the  lime  salts  at  the  lower  end  of  the  bone.  The  greatest  area  of 
involvement,  however,  is  seen  in  the  ulna,  where  the  periosteum  is 
markedly  thickened,  being  almost  as  thick  as  the  structure  of  the 
bone  itself.  On  the  outer  edge  of  the  olecranon  there  is  seen  to  be  a 
beginning  destruction  of  the  periosteum.  The  whole  olecranon  at 
its  upper  third  is  completely  changed  from  its  normal  structure. 
The  radius,  however,  shows  little  disturbance  beyond  the  periosteal 
reaction  to  be  expected  in  this  condition.  There  is  a  marked  in- 
crease in  the  radiability  of  all  the  bones  in  this  plate. 

Ulna. — Fig.  2  represents  a  syphilitic  lower  arm  in  a  child  four 
and  a  half  years  old.  There  is  a  very  thick  layer  of  periosteum 
on  either  side  of  the  lower  part  of  the  shaft  of  the  ulna.  On  the 
outer  side  of  the  ulna  the  tissues  are  thickened  and  there  is  a  forma- 
tion of  abscess  in  the  soft  parts.  Such  a  bone  as  this  is  absolutely 
characteristic  of  retarded  syphilis. 


THE  EXTREMITIES.  201 

Dactylitis. — Plate  237  shows  a  syphilitic  dactylitis  in  a  child 
two  5'ears  old.  There  is  infection  of  the  first  and  third  metacarpal 
bones  and  of  the  first  phalanx  of  the  fourth  finger.  It  is  to  be  noted 
that  there  is  veiy  little  change  in  the  structure  of  the  bone,  but  a 
great  change  is  seen  in  the  thickened  periosteum.  There  is  con- 
siderable tissue  reaction  and  much  fine  pencilling  of  the  bone  tissue. 

Tibia:  Periostitis. — Plate  238  represents  a  syphilitic  periostitis 
of  the  tibia  in  a  child  five  years  old.  There  is  bulging  of  the  soft 
parts  on  either  side  of  the  tibia  and  fibula.  The  periosteum  along 
the  whole  of  the  tibia,  and  also  of  the  fibula,  is  thickened  in  a  char- 
acteristic manner.  There  is  also  apparently  some  thickening  of  the 
cortical  substance. 

Tibia:  Periostitis. — Plate  239  shows  a  syphilitic  periostitis  of 
the  tibia  in  a  cliild  eight  years  old.  This  is  a  lateral  view.  The  out- 
line of  the  bone  along  the  anterior  border  of  the  tibia  is  sUghtly  more 
convex  than  normal,  with  a  slight  prominence  in  the  upper  third  of 
the  bone  posteriorly.  On  the  anterior  surface  the  thickening  of  the 
periosteum  extends  along  the  shaft  and  down  towards  the  lower 
third. 

Osteoperiostitis  and  Osteochondritis. — Plate  240  shows  a  syphilitic 
osteoperiostitis  and  osteochondritis  in  a  case  of  congenital  syphilis 
in  a  colored  child  six  weeks  old.  The  infant  was  breast-fed.  'WTien 
four  weeks  old  it  developed  a  pseudoparalysis  of  the  left  arm  and 
leg,  with  marked  tender  swellings  at  the  elbows  and  knees.  There 
was  an  enlargement  of  the  spleen  and  liver,  and  a  squamous  desqua- 
mation of  the  soles  of  the  feet  and  palms  of  the  hands.  There  were 
fissures  at  the  anus.  The  enlargement  of  the  upper  ends  of  the  tibia 
and  fibula,  and  of  the  lower  ends  of  the  femur,  was  very  much 
marked.  The  Roentgenograph  shows  an  osteochondritis  with  in- 
volvement of  the  diaphyses  of  the  femora  and  of  the  tibia  and  fibula, 
and  great  thickening  of  the  periosteum. 


202  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Retarded  Syphilis,  Tibia  and  Fibula. — Plate  241  was  a  case  of 
retarded  syphilis  in  a  child  twelve  years  old.  This  child  had  the 
lesions  of  retarded  syphilis  in  other  bones  of  the  body.  This  plate 
shows  the  left  side  of  the  tibia  and  fibula.  The  lower  third  of  the 
tibia  shows  an  area  of  active  suppuration  with  beginning  formation 
of  sequestrum.  The  whole  lower  part  of  the  tibia  is  seen  to  have 
areas  of  increased  radiability.  The  periosteum  is  seen  to  be  thick- 
ened along  the  whole  length  of  the  tibia,  and  of  the  fibula  also.  The 
process  in  the  tibia  extends  apparently  down  to  the  epiphyseal  hne 
but  does  not  involve  the  ankle-joint.  There  is  also  increased  radia- 
bility of  the  shaft  of  the  fibula.  The  bones  of  the  foot  are  seemingly 
normal. 

TUBERCULOSIS 

Much  has  been  studied  in  connection  with  and  much  progress 
made  in  tuberculosis  of  the  lungs,  but  we  should  understand  that 
of  equal,  if  not  greater,  importance  is  a  consideration  of  tuberculosis 
of  the  bones. 

There  are  a  number  of  facts  which  make  a  study  and  conse- 
quently a  knowledge  of  tuberculosis  of  the  bones  of  great  importance. 

In  order  to  diagnosticate  tubercular  conditions  and  to  enable 
us  to  differentiate  tubercular  from  non-tubercular  lesions  it  is  of 
the  utmost  moment  that  we  should  recognize  the  normal  li\dng 
anatomy  of  the  bones  at  different  periods  of  their  development,  as 
portrayed  by  the  Roentgen  ray.  This  is  especially  necessary  in 
the  early  stages  of  tubercular  disease,  where  the  pathologic  changes 
are  often  slight  and  obscure,  and  yet  where  an  early  diagnosis  is 
extremeh'  valuable.  This  often  enables  us  to  arrest  the  disease  by 
treatment,  and  to  determine  whether  the  condition  is  merely  a 
slight  anomaly  of  healthy  bone  or  some  non-tubercular  affection. 
In  both  these  latter  conditions  we  can  often  decide  that  the  case 
is  not  tubercular,  and  therefore  not  one  to  be  sent  to  tubercular 


THE  EXTREMITIES.  203 

hospitals  or  homes.  It  is  also  important  that  the  treatment  in 
tuberculosis  should  be  begun  very  early,  so  as  to  protect  the  ear 
and   other  organs  from  secondary'  infection. 

There  is  no  diagnostic  means  so  valuable  for  the  detection  of 
tuberculosis  of  the  bones  as  the  Roentgen  ray  in  the  hands  of  experts 
in  its  technic.  Over  and  over  again  it  becomes  a  most  important 
factor  in  the  chain  of  evidence  which  may  lead,  unless  refuted  by  the 
ray,  to  stamping  an  indi\'idual  as  syphilitic,  and  thus  perhaps  ruin- 
ing his  social  life. 

Witness  the  possible  differentiation  by  the  ray  of  the  tubercu- 
lar lesions  of  the  bones  from  the  periosteal  lesions  of  s}'philis  and 
the  especial  lesions  represented  by  dactylitis.  Again,  the  importance 
of  differentiating  by  the  Roentgen  method  a  non-tubercular  from 
a  tubercular  arthritis,  and  a  tubercular  hip  from  an  osteomyelitis 
or  an  acute  trauma,  is  very  great. 

In  the  past,  and  very  often  in  the  present,  many  cases  have 
been  considered  and  treated  as  tubercular  which  have  really  been 
non-tubercular.  The  Roentgen  method  often  corrects  us  when 
we  have  been  mistaken  in  making  a  diagnosis  of  tuberculosis,  and 
shows  us  that  if  the  true  diagnosis  had  been  made,  an  entirely 
different  treatment  would  have  been  indicated. 

We  may  tabulate  our  knowledge  of  the  pathologic  findings, 
and  understand  the  terminal  lesions  at  the  autopsy;  we  may  make 
advances  in  the  treatment  of  tuberculosis;  but  how  significant  is 
the  announcement  in  the  sanatoria  that  early  cases  of  tuberculosis 
are  preferably  taken,  or  often  only  taken!  The  diagnosis  of  these 
early  cases,  especially  where  the  bones  are  affected,  is  exceedingly 
difficult  without  the  aid  of  the  Roentgen  ray,  even  when  a  thorough 
clinical  examination  has  been  made,  and  especially  in  those  cases 
where  the  tuberculin  test  has  failed.  Most  important  of  all,  next 
to  the  actual  operative  indications  which  the  Roentgen  ray  gives 


204  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

US,  is  its  differentiation  of  tuberculosis  of  the  bones  in  doubtful  and 
obscure  cases  from  conditions  caused  by  osteomyelitis,  syphilis, 
and  trauma.  Probably  thousands  of  lives  could  be  saved  if  cases  of 
tuberculosis  could  be  recognized  before  the  later  and  more  advanced 
lesions  have  appeared,  with  their  almost  hopeless  prognosis. 

There  are  certain  early  lesions  in  tuberculosis  of  the  bones 
which  can  be  detected  by  means  of  the  Roentgen  ray.  One  of  the 
first  manifestations  of  a  tuberculous  lesion  of  the  bones  is  atrophy 
of  the  shaft  of  the  bone,  especially  of  the  femur  or  of  the  humerus. 
This  may  occur  long  before  a  definite  focus  of  disease  is  discernible, 
and  this  atrophy  of  size  as  well  as  of  quality  of  the  bone  is  noticed 
to  increase  progressively. 

The  infection  commonly  attacks  the  epiphyses  of  the  long 
bones,  and  is  first  detected  by  the  Roentgen  method  as  a  small 
area  of  increased  radiability.  This  area  slowly  increases  in  size  and 
shows  an  atrophy  of  the  bone  about  the  point  of  infection  dispro- 
portionate to  the  amount  of  diseased  bone  apparent.  This  atrophy 
may  be  due  partly  to  the  infection,  but  is  also  due  to  the  slow  prog- 
ress of  the  disease  and  to  disuse  of  the  part. 

The  value  of  the  Roentgen  ray  in  detecting  diseases  of  the  bones 
is  very  great,  because  it  indicates  the  exact  location  of  the  infec- 
tion, and  the  details  of  the  li^^ng  gross  pathologA'.  Primary'  infec- 
tion of  a  bone  in  children  by  the  bacillus  of  tubercle  always  occurs 
in  the  epiphyses  except  where  the  child  is  of  an  age  at  which  the 
given  bone  has  no  ossific  centre.  The  early  lesions  of  tuberculosis 
of  the  bones  which  can  be  detected  by  means  of  the  Roentgen  ray  are: 

Atrophy  in  size  of  the  bone  at  the  upper  part  of  the  femur  as 
a  rule  is  present.  In  the  joints  we  find  frequently  hj'per- 
troph}^  in  the  early  stages  followed  later  by  atrophy. 

Atrophy  in  quality  of  the  substance  of  the  bone. 

A  definite  area  of  necrosis  of  the  bone. 


THE  EXTREMITIES.  205 

Examination  by  the  Roentgen  method  shows  just  at  what  por- 
tion of  the  bone  the  disease  begins  in  a  given  case,  whether  in  the 
epiphysis  or  in  the  diaphysis.  It  will  show  also  the  relative  size  of 
the  diseased  areas.  It  will  show  the  lack  of  definiteness  of  the  struc- 
ture of  the  bone  which  accompanies  atrophy,  change  in  quality  due 
to  an  absorption  of  lime  salts,  or  a  disintegration  of  the  bone  into 
caseous  material.  ^\Tiere  a  joint  is  infected  by  the  bacillus  of 
tubercle,  erosion  of  the  surface  of  the  joint  usually  begins,  by  either 
a  definite  focus  at  one  point  or  a  definite  erosion  at  some  portion. 

In  cases  of  tuberculosis  of  the  knee-joint  one  of  the  earliest 
manifestations  is  usually  atrophy  of  the  soft  parts.  In  the  epiphyses, 
however,  there  is  at  first  apparent  increase  in  size  but  atrophy  in 
the  texture  of  the  bones.  There  is  an  increased  density  in  the  cap- 
sule, due  in  all  probabilit}'^  to  tliinning  or  possibly  fluid  within  the 
joint;  there  is  also  squaring  and  atrophy  of  the  epiphyses.  A  focus 
may  be  defined,  although  in  the  majority  of  cases  it  is  not  found 
early.  We  also  notice  an  early  stimulation  of  epiphyseal  growth 
and  an  appearance  of  hypertrophy  of  the  shaft  and  of  the  epiphj-ses. 
This  is  usually  accounted  for  by  the  marked  increase  of  the  blood 
supply,  which  would  naturally  produce  an  h3-pertrophy.  This 
accounts  also  for  the  increased  length  of  a  given  part. 

As  the  process  becomes  more  extensive  the  characteristic  fea- 
tures are  generally  atrophy  of  the  soft  parts,  atrophy  of  the  cortex, 
increased  density  of  the  cortex,  increase  of  the  medullary  canal 
at  the  expense  of  the  cortex,  and  a  lack  of  definition  of  the  structure 
of  the  bone.  Within  the  joint  affected  we  find  more  or  less  actual 
destruction  of  bone  with  detritus  about  the  focus  of  infection,  erosion 
of  the  surfaces  of  the  joints,  increase  in  the  density  of  the  capsule, 
and  lack  of  definition  of  the  structure  of  the  bone  generally. 

One  of  the  first  manifestations  of  an  infection  by  the  bacillus 
of  tubercle  is  usually  atrophy  of  the  size  of  the  bone.    This  occurs 


206  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

long  before  a  definite  focus  of  disease  is  discernible  either  by  the 
eye  or  in  the  Roentgenographs.  The  epiphj'ses  of  the  long  bones, 
or  the  acetabulum,  are  first  infected,  and  this  is  detected  by  means 
of  the  Roentgen  ray  as  a  small  area  or  areas  of  increased  radiability. 
This  area  slowly  increases  in  size  and  shows  an  atrophy  of  the  bone 
about  the  infected  point,  so  that  the  dense  qualities  of  the  bone 
are  reduced  to  that  of  its  surrounding  soft  parts. 

At  times  the  only  noticeable  change  from  the  normal  is  in  the 
marked  atrophy  of  size  without  evidence  of  destruction  of  the  bone, 
and  at  times  an  infiltration  of  the  tissues  and  capsule  with  the  for- 
mation of  an  abscess.  The  bacilli  of  tubercle  do  not  cause  periosteal 
reaction,  and  when  this  reaction  is  seen  in  the  Roentgenograph  it 
shows  that  there  has  been  a  mixed  infection. 

A  point  of  interest  in  the  examination  of  a  large  number  of 
cases  of  tuberculosis  in  children  by  the  Roentgen  method  is  that 
it  demonstrates  repeatedly  the  clinical  manifestations  of  tubercu- 
losis of  the  joint  without  definite  foci  being  detected  in  the  bone, 
though  a  great  deal  of  capsular  thickening  may  be  evident.  It  is 
unusual  to  find  a  distinct  early  necrosis  of  the  bone. 

In  the  very  chronic  cases,  when  examined  by  the  Roentgen 
method,  we  find  the  characteristic  reconstruction  going  on  to  anky- 
losis and  to  new  formation  of  bone. 

In  connection  with  the  differential  diagnosis  between  osteo- 
myelitis and  tuberculosis,  it  is  well  known  that  various  pathogenic 
infections  may  result  in  acute  and  chronic  osteomyelitis.  If  the 
specific  cause  of  these  infections  is  recognized  early,  the  treatment 
often  differs  decidedly  from  that  which  should  be  employed  where 
the  infection  is  tubercular.  By  means  of  the  Roentgen  method  we 
can  often  localize  the  pathologic  process  before  the  infected  area 
has  increased  very  much.  We  can  also  almost  at  once  determine 
whether  the  infection  has  attacked  the  bone  to  any  great  extent. 


THE  EXTREMITIES.  207 

Atrophy. — Atrophy  of  bone  as  demonstrated  by  the  Roentgen 
method  has  become  important  enough  to  be  spoken  of  in  detail. 
It  is  evident  that  three  kinds  of  atrophy  are  seen, — (1)  atrophy  of 
size,  (2)  atrophy  of  the  quaUty  of  the  substance  of  the  bone,  or  (3) 
a  combination  of  both. 

It  is  characteristic  that  certain  organisms  produce  characteristic 
changes  in  a  bone  which  are  more  or  less  constant.  In  infection 
of  a  bone  by  the  bacillus  of  tubercle,  particularly  about  a  large 
joint,  such  as  that  of  the  hip,  one  of  the  early  manifestations  of  the 
infection  will  be  a  marked  atrophy  in  the  size  of  the  femur.  This 
is  demonstrated  long  before  any  actual  disease  is  apparent,  unless 
it  is  a  mixed  infection. 

Certain  authorities  have  demonstrated  by  Roentgenographs 
that  an  atrophy  of  bones  in  juxtaposition,  such  as  the  os  pubis  and 
ischium,  takes  place  with  an  apparent  hypertrophy  of  the  iUum. 
In  a  great  majority  of  these  cases  misinterpretation  may  arise  re- 
sulting from  a  deformity  of  the  pelvis  brought  on  bj^  postural  or 
structural  change  which  the  femur  undergoes,  due  to  traction  ap- 
plied in  carrying  out  the  treatment.  Under  these  circumstances 
the  pelvis  may  be  distorted  in  its  relation  to  the  healthy  side,  so 
that  a  twist  of  the  innominate  bone  on  the  side  of  the  infection, 
whereb}^  the  greatest  width  is  brought  into  view,  w'ill  give  an  appar- 
ent atrophy  of  the  os  pubis  and  of  the  ischium. 

Atrophy  of  the  size  of  the  bone  will  be  evident  in  the  bones 
adjacent  to  the  larger  joints.  The  question  has  come  up  repeatedly 
whether  atrophy  of  size  is  due  to  a  specific  disease  or  to  disuse. 
Experimentally,  Dr.  A.  T.  Legg  claims  that  atrophy  of  size  is  not 
due  to  disease  but  to  disuse.  However,  the  fact  is  recognized  that  the 
osseous  and  muscular  systems  of  indi\'iduals  suffering  from  diseases 
such  as  general  tuberculosis  are  not  able  to  withstand  immobilization 
as  well  as  healthy  individuals.     It  is  reasonable  therefore  to  sup- 


20S  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

pose  that  a  person  suffering  from  tuberculosis,  and  for  some  reason 
treated  by  immobilization  of  a  given  part,  would  have  more  atrophy 
of  the  size  of  the  bone  than  would  be  evident  in  an  individual  who 
was  perfectly  well  ha\'ing  the  same  amount  of  immobilization. 

The  first  change  that  takes  place  with  immobilization  either 
for  a  fracture  or  experimentally  is  the  marked  re-arrangement  of 
the  structure  of  the  bone,  so  that  the  bone  becomes  apparently 
porous,  the  interspaces  between  the  trabeculse  being  demonstrated 
more  clearly.  Under  these  conditions  the  trabeculae  stand  out  a 
little  more  definitely  without  any  apparent  change  in  size.  This 
appearance  is  t\'pical  of  the  atrophy  seen  in  a  foot  where  there  is 
a  Pott's  fracture,  or  in  a  fracture  where  immobilization  has  been 
used.  In  a  healthy  individual  this  appearance  will  progress  more 
or  less  indefinitely.  In  a  person  suffering  from  some  constitu- 
tional disease,  or  infection,  where  the  nutrition  of  the  given  part  is 
disturbed  or  has  not  the  equivalent  of  a  healthy  individual's  blood 
supply,  there  is  on  the  contrary  a  change  in  the  natural  size  of  the 
bone  with  a  marked  absorption  of  the  structure  of  the  bone. 

Where,  for  any  reason,  there  is  an  increased  supply  of  blood 
to  a  given  part,  and  the  case  becomes  more  or  less  chronic,  it  is 
demonstrated  that  the  part  enlarges  or  hypertrophies  in  comparison 
with  the  healthy  and  unaffected  side.  This  is  seen  in  clironic  osteo- 
myelitis and  in  chronic  synovitis. 

We  can  have  also  a  combination  of  both  atrophy  of  quality 
and  atrophy  of  size  in  which  there  is  a  decrease  of  the  size  of 
the  bone  with  an  absorption  of  the  lime  salts.  This  is  seen  in  the 
chronic  forms  of  arthritis,  as  well  as  in  tuberculosis  of  the  bone  or 
in  general  tuberculosis.  It  is  also  seen  in  paralytic  conditions,  such 
as  poliomyelitis  anterior,  and  in  some  of  the  malignant  osteomata, 
where  spontaneous  fracture  takes  place  usually  near  the  origin  of 
the  nutrient  arterj'.    This  fracture  usually  extends  in  both  directions. 


THE  EXTREMITIES.  209 

causing  diminution  in  the  size  of  the  bone,  and  actual  absorption 
of  the  bone  substance  without  any  tendency  towards  the  formation 
of  a  callus. 

Tubercular  Dactylitis. — This  is  a  condition  in  which  there  is 
a  fusiform  dactylitis  of  the  fingers  or  toes,  which  may  attack  one 
or  more  bones  in  one  or  both  hands.  It  is  characterized  in  the 
early  stage  by  a  beginning  destruction  about  a  focus  in  the  interior 
of  the  bone  and  sometimes  has  the  appearance  of  a  cystic  formation 
of  the  bone. 

In  a  later  stage  of  the  disease,  destruction,  or  more  definitely, 
absorption  of  the  whole  interior  of  the  medullary  canal  of  the  bone 
takes  place  with  a  re-arrangement  of  the  structure  of  the  bone. 
This  at  times  looks  as  if  it  were  one  big  cyst  or  multiple  cysts,  and 
the  bone  is  larger,  and  usually  has  a  very  thin  cortex  if  any. 

The  adjacent  joints  are  not  usually  affected.  This  condition 
goes  on  to  thickening,  enlarging  of  the  phalanx,  and  sometimes 
sequestrum  in  its  interior.  Suppuration  may  occur  with  discharge 
of  one  or  more  sequestra,  leaving  a  permanent  deformity,  usually 
a  shortening  of  the  affected  finger.  Commonly,  however,  healing 
takes  place  without  much  change  in  the  growth. 

Metatarsal  Bone. — Plate  242,  Fig.  1,  represents  a  destruction  of 
cortical  bone  and  a  shght  cavity  in  the  fourth  metatarsal  bone 
in  a  girl  twelve  years  old.  The  lesions  suggest  a  tubercular  process, 
or  possibly  a  benign  cyst  of  the  bone. 

Tubercular  Dactylitis. — Fig.  2  represents  tubercular  dactylitis 
in  a  boy;  age,  three  years;  parents  healthy.  There  was  no  tuber- 
culosis in  the  family  history.  The  nurse  was  probably  tubercular. 
The  child  was  well  until  five  months  old,  when  a  swelling  appeared 
in  the  upper  part  of  the  tibia,  just  below  the  patella;  at  this  time 
also  a  swelling  of  the  first  phalanx  of  the  middle  finger  of  the  right 
hand  and  the  second  phalanx  of  the  middle  finger  of  the  left  hand 
appeared. 

14 


210  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

Through  a  misapprehension  of  the  serious  nature  of  the  case 
by  the  physician  in  charge  (who  was  inclined  to  make  the  diagnosis 
of  s)-phihs  on  account  of  the  dactyhtis)  nothing  especial  was  done, 
except  to  live  at  a  sanatorium  until  January,  1907,  when  a  Roentgen- 
ograph was  taken.  The  true  lesions  were,  therefore,  not  recognized 
for  some  time,  and  in  March,  1907,  a  secondary  infection  of  the 
dorsal  vertebrae  took  place. 

The  plate  shows  a  distinct  area  of  destruction  of  the  bone  in 
the  middle  phalanx  of  the  middle  finger  of  the  right  hand,  without 
any  evidence  of  proliferation  of  the  periosteum.  The  first  phalanx 
of  the  middle  finger  in  the  left  hand  shows  the  result  of  a  pre\aous 
destructive  process,  but  at  the  time  when  the  Roentgenograph 
was  taken  there  was  new  formation  of  the  bone. 

Atrophy  from  Disuse.  —  Plate  243  .represents  the  knees  of  a 
child  twelve  years  old.  A  clinical  diagnosis  of  tuberculosis  of  the 
knee  was  made  in  this  case,  and  it  was  treated  as  such  for  two  years. 
A  series  of  Roentgenographs  of  this  case  were  then  taken  at  inter- 
vals, and  at  no  time  was  any  change  noticed  in  the  bones  which 
would  suggest  tuberculosis.  On  the  contrary,  the  marked  atrophy 
of  the  bone  and  its  lessened  radiability  pointed  more  to  disuse  than 
to  disease.  That  is,  it  was  an  atrophy  of  the  quality  of  the  bone 
substance  rather  than  the  atrophy  of  size  which  is  characteristic 
of  tuberculosis.  It  was  the  treatment  with  a  stiff  plaster  bandage 
which  had  produced  this  condition. 

Tubercular  Dactylitis. — Plate  244  represents  a  tubercular  dac- 
tylitis occurring  in  a  child  two  and  a  half  years  old.  It  shows 
the  enlargement  of  the  first  phalanx  of  the  second  and  fourth  fingers. 
It  will  be  seen  that  there  is  a  marked  change  in  the  structure  of  the 
bone,  also  giving  it  the  appearance  of  a  cystic  formation,  there 
being  considerable  absorption.  It  is  to  be  noted  that  there  is  very 
little  involvement  of  the  periosteum,  apparently  none.  The  other 
bones  of  the  hand  show  in  certain  areas  an  osteoporosis. 


THE  EXTREMITIES.  211 

Tubercular  Dactylitis. — Plate  245  represents  a  case  of  tuber- 
cular dactylitis.  The  soft  parts  around  the  infected  areas  are  seen 
to  be  markedly  thickened,  the  fingers  having  the  spindle-shaped 
appearance.  The  first  and  third  metacarpal  bones  are  affected, 
and  there  is  marked  disturbance  of  the  first  phalanx  of  the  fourth 
finger,  with  apparently  an  almost  cystic  formation.  It  is  to  be  noted 
that  there  is  very  little  periosteal  reaction.  In  this  way  it  differs 
markedly  from  syphilitic  dactylitis. 

Ulna:  Necrosis. — Plate  246  shows  an  area  of  necrosis  of  the  bone 
in  the  lower  end  of  the  ulna  with  a  small  formation  of  sequestrum. 
There  is  also  some  atrophy  of  quaUty. 

Carpal  Bones.  —  Plate  247  represents  a  tubercular  condition 
of  the  carpal  bones  of  the  hands  of  a  child  five  years  old.  In  the  left 
hand  (1)  it  is  to  be  noted  that  the  soft  parts  are  greatly  thickened 
and  that  there  is  destruction  in  some  of  the  carpal  bones.  This 
process  was  undoubtedly  due  to  a  tubercular  infection.  The  right 
hand  (2)  is  normal. 

Elbow-joint. — Plate  248  represents  a  tubercular  process  in  the 
elbow-joint  of  a  child  eight  years  old.  The  soft  parts  show  a 
thickening  and  haziness.  The  lower  end  of  the  humerus  shows 
some  periosteal  reaction,  although  the  contour  is  regular.  The 
ulna  on  the  outer  edge  of  the  olecranon  shows  an  area  of  increased 
radiability,  due  to  absorption  of  the  Ume  salts  and  to  the  gradual 
extension  of  the  tubercular  process.  The  periosteum  of  the  ulna 
is  somewhat  thickened  and  the  radius  shows  some  decrease  in  its 
Ume  salts. 

Hip-joint:  Mixed  Infection. — Plate  249  represents  a  tubercular 
hip-joint  caused  by  a  mixed  infection  in  a  child  five  years  old. 
The  density  of  the  soft  parts  around  the  left  hip  is  markedly  in- 
creased. It  will  be  seen  that  the  shaft  of  the  femur  shows  a  de- 
creased radiability,  due  to  absorption  of  the  substance  of  the  bone. 


212  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

The  periosteum  along  the  iliopcctineal  line  is  greatly  thickened. 
This  periosteal  thickening  is  probably  not  due  to  the  bacillus  of 
tubercle,  but  to  marked  reaction,  indicating  probably  a  mixed 
infection. 

Acetabulum. — Plate  250  represents  a  boy  twelve  years  old  show- 
ing marked  disease  of  the  whole  acetabulum  and  a  mottled  appear- 
ance of  a  decreased  radiability.  The  head  of  the  femur  has  prac- 
tically disappeared  and  there  is  a  general  involvement  of  the  whole 
neck  and  greater  trochanter,  as  is  also  shown  by  the  mottled  appear- 
ance. There  is  practicalh'  no  tissue  reaction  to  be  seen  in  this  plate. 
The  shaft  of  the  femur  is  negative. 

Hip:  Mixed  Infection. — Plate  251  shows  a  mixed  infection  of 
the  hip  with  great  involvement  of  the  whole  head  of  the  bone  and 
destruction  of  the  upper  epiphysis  of  the  femur. 

Hip.  —  Plate  252  represents  the  result  of  an  old  tubercular 
process  in  the  hip  of  a  child  fourteen  years  old.  The  dotted  line 
shows  where  the  head  of  the  femur  would  naturall}'  be.  The  acetab- 
ulum is  practically  destroyed  by  the  disease.  There  is  no  regular 
outline,  but  the  process  can  be  seen  to  be  inactive.  The  femur  is 
seen  to  be  ossified  to  the  ilium  just  above  the  acetabulum  and  there 
is  atrophy  in  the  region  of  the  greater  trochanter.  The  greater 
trochanter,  however,  is  not  to  be  seen. 

Acetabulum  and  Femur:  Necrosis.  —  Plate  253  represents  a 
tubercular  condition  of  the  diaphysis  of  the  femur  in  a  boy  eight 
years  old.  The  picture  shows  a  focus  of  the  diaphysis  of  the  right 
femur  marked  as  an  area  of  increased  radiability,  due  to  absorption 
of  the  lime  salts  and  to  necrosis  of  the  bone.  This  area  is  surrounded 
by  a  finely  pencilled  line  denoting  the  formation  of  new  bone,  cor- 
responding to  nature's  effort  to  wall  ofif  the  diseased  area.  The 
epiphysis  also  shows  the  presence  of  disease  by  its  irregular  artic- 
ulating surface  and  the  destruction  of  bone  that  has  taken  place. 


THE  EXTREMITIES.  213 

The  outline  of  the  acetabulum  is  also  irregular,  due  to  the  same 
process. 

Hip. — Plate  254  represents  an  infectious  hip  in  a  child  five 
years  old.  In  examining  the  two  hip-joints  in  this  case  it  will  be 
seen  in  the  first  place  that  the  soft  parts  of  the  left  hip-joint  have 
a  markedly  increased  radiabihty.  The  outline  of  this  increased 
area  of  density  is  clearly  marked.  There  is  also  an  area  of  infection 
in  the  neck  of  the  right  femur.  It  will  be  noted  in  comparing  this 
femur  with  the  femur  on  the  other  side  that  there  is  no  atrophy  of 
the  shaft  of  the  femur  nor  of  the  bones  of  the  pelvis.  It  will  be 
seen  that  the  epiphyseal  line  of  the  left  femur  shows  lessened  radia- 
bihty. The  epiphysis  on  the  left  will  be  seen  to  have  an  increased 
radiabihty  as  compared  with  the  right  side.  The  dotted  Unes  on 
the  left  show  diagrammatically  the  arrangement  of  the  joint-cap- 
sules made  hy  the  anterior  and  the  posterior  insertions  of  the  cap- 
sule. The  dotted  lines  on  the  right  represent  the  capsule  distended 
with  pus.  On  an  earlier  examination  the  disease  was  noted  outside 
of  the  capsule,  but  when  this  picture  was  taken  it  had  extended 
into  the  capsule. 

Hip-ioint.^^\aXe  '2bb  represents  the  picture  of  tuberculosis  of 
the  hip-joint  in  a  girl  eight  years  old.  There  is  a  marked  density 
of  the  soft  parts  around  the  left  hip-joint.  There  is  atrophy  of  both 
size  and  quality  of  the  shaft  of  the  left  femur.  There  is  partial 
absorption  of  the  neck  and  head  of  the  femur  and  marked  involve- 
ment is  shown  by  the  increased  radiabihty  and  destruction  of  out- 
hne  of  the  acetabulum.  There  is  also  atrophy  of  all  the  bones  of 
the  pelvis  on  this  side  as  compared  with  the  other. 

Knee-joint. — Plate  256  shows  an  early  tuberculosis  of  the 
knee-joint  of  a  child  five  years  old.  There  is  increased  density 
about  the  knee-joint,  which  shows  thickening  of  the  soft  parts  and 
capsule.    There  is  a  roughening  of  the  epiph3'sis  of  the  femur  with 


214  THE    ROENTGEN  RAY  IN  PEDIATRICS. 

as  yet  no  destruction  of  boue.  There  is,  however,  a  slight  amount 
of  atrophy  in  the  shafts. 

Knee-joint.  —  Plate  257  represents  a  tuberculous  knee-joint 
in  a  child  eight  years  old.  There  is  a  marked  thickening  of  the  soft 
parts  and  of  the  capsule  around  the  knee-joint.  There  is  atrophy  of 
quality  as  well  as  of  size  of  the  bones.  The  condyles  are  irregular  in 
outline  and  there  is  an  irregular  development  of  the  patella.  The 
epiphysis  of  the  femur  is  irregular  in  outline. 

Thigh:  Abscess. — Plate  258  shows  an  encapsulated  abscess  of 
the  thigh  in  a  boy  six  years  old.  The  lateral  view  of  the  thigh  shows 
a  definitely  encapsulated  abscess  in  the  anterior  lower  aspect.  The 
tissues  around  the  knee-joint  are  markedly  thickened.  The  con- 
dyles and  epiphysis  of  the  femur  are  very  irregular  in  outline,  as  is 
also  the  upper  end  of  the  tibia.  There  is  atrophy  of  quality  as  well 
as  of  size  of  the  femur  and  also  of  the  tibia  and  fibula.  There  is  no 
absolute  destruction  of  bone. 

Tibia,  Epiphysis.  —  Plate  259  represents  tuberculosis  of  the 
epiphysis  of  the  tibia.  The  shaft  of  the  tibia  and  fibula  and  the 
epiphyseal  line  of  the  tibia  are  perfectly  normal.  There  will  be  seen 
a  small  focus  on  the  posterior  aspect  of  the  epiphysis  of  the  tibia. 
There  is  almost  complete  absorption  of  bone  in  this  area.  There  is 
no  formation  of  sequestrum.     The  bones  of  the  foot  are  normal. 

Os  Colds:  Abscess. — Plate  260  represents  tuberculosis  of  the 
OS  calcis  in  the  foot  of  a  child  two  and  a  half  years  old.  On  the 
dorsum  of  the  foot  is  a  well-defined  abscess.  The  primary  focus 
is  on  the  anterior  aspect  of  the  os  calcis,  where  there  is  seen  to  be 
actual  destruction  of  about  one-half  of  the  bone.  The  other  bones 
of  the  foot  show  an  osteoporosis. 

Ankle  and  Foot:  Abscess. — Plate  261  shows  in  the  ankle-joint 
of  a  girl  four  years  old  a  definitely  walled  abscess  consisting  either 
of  fluid  or  thickened  tissue.    The  lower  end  of  the  tibia  shows  marked 


THE  EXTREMITIES.  215 

absorption  of  lime  salts  and  increased  radiability.  The  epiphysis 
of  the  tibia  and  the  astragalus  show  marked  destruction  of  the 
structure  of  the  bone.  They  are  apparently  within  the  cavity  of 
the  abscess.  The  metatarsal  bones  show  the  same  absorption  of 
lime  salts  as  does  the  lower  end  of  the  tibia.  There  is  an  atrophy 
of  size  as  well  as  of  quality.  The  change  in  quality  is  shown  in  the 
OS  calcis  by  its  finely  pencilled  outline.  The  case  was  probably 
tubercular. 

Ankle:  Tuberculosis. — Plate  262  shows  a  tubercular  ankle  in 
a  child  five  years  old.  The  soft  tissues  surrounding  the  ankle  are 
greatly  thickened  and  infiltrated.  There  is  a  slight  amount  of  in- 
creased radiability  of  the  tibia  as  well  as  of  the  os  calcis.  The  epiphy- 
sis of  the  tibia  shows  an  actual  destruction  in  its  lower  end  and  an 
involvement  of  the  astragalus  on  its  articulating  surface. 

Astragalus  and  Os  Calcis:  Tuberculosis. — Plate  263  represents 
a  tuberculosis  of  the  astragalus  and  of  the  os  calcis  in  a  boy  twelve 
years  old.  There  is  a  thickening  of  the  soft  parts  around  the  ankle 
and  an  area  of  actual  destruction  of  the  posterior-inferior  portion 
of  the  astragalus  and  of  the  superior  border  of  the  os  calcis.  There 
has  been  both  destruction  and  absorption.  The  bones  of  the  foot 
show  a  finely  pencilled  outline,  as  does  the  lower  end  of  the  tibia, 
representing  atrophy  in  quality  in  these  parts,  although  there  is 
no  actual  involvement. 

NON.TUBERCULAR  INFECTIONS 

In  the  acute  pyogenic  infections  within  the  joint  we  have 
classical  symptoms  of  acute  infection  of  the  joint,  acute  onset, 
rapid  distention  of  the  joint,  much  pain,  and  constitutional  dis- 
turbance. 

The  subacute  or  chronic  cases  of  intra-articular  pyogenic  infec- 
tion may  differ  in  no  respect  clinically  from  tuberculosis  in  its  early 
stages,  but  will  clear  up  much  earlier  than  tuberculosis,  with  possibly 


21G  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

a  perfect  recovery  of  function.  This  type,  however,  may  show  an 
ultimate  permanent  lengthening  from  the  irritation  of  the  epiphys- 
eal cartilage. 

Little  need  be  said  of  the  early  diagnosis  of  the  acute  pyogenic 
infections,  except  of  its  importance  in  demanding  operative  inter- 
ference. 

In  the  chronic  cases  of  pyogenic  infection  with  symptoms 
identical  with  those  of  tuberculosis  of  the  hip,  we  should  hesitate 
to  make  a  differential  diagnosis  until,  after  careful  watching  and 
repeated  Roentgenographs,  we  could  detect  the  beginning  of  a  de- 
structive process  demanding  operative  interference. 

These  particular  cases  of  pyogenic  infection  resulting  in  acute 
and  chronic  osteomyelitis  vary  in  no  detail  as  to  our  conception 
of  osteomyehtis  in  its  pathologic  process.  According  to  Legg  and 
George  it  is  apparent  that  these  cases  are  very  commonly  confused 
with  tuberculosis,  but  if  recognized  the  subsequent  early  treatment 
will  differ  radically  from  that  of  tuberculosis.  The  ultimate  result 
as  to  early  recovery  and  as  to  the  function  of  the  part  will  be, 
however,  vastly  better. 

In  order  to  recognize  this  class  of  cases  early  we  must  use  all 
the  means  at  our  disposal  and  make  a  most  careful  clinical  examina- 
tion; the  Roentgen  ray,  however,  plays  the  most  important  part 
in  the  diagnosis: 

1.  In  the  location  of  the  pathologic  process. 

2.  In  the  early  recognition   of   the  extent  of   the  pathologic 

process. 
1.  Location.  —  An  infection  by  a  pyogenic  organism,  though 
it  may  occur  in  the  epiphysis,  is  most  commonly  found  in  the 
diaphysis,  or  shaft  of  the  bone,  and  it  will  usually  be  outside  of  the 
insertion  of  the  joint-capsule  and  within  the  boundaries  of  the 
periosteum.     Statistics,  however,  do  not  altogether  agree  with  this, 


THE  EXTREMITIES.  217 

as  Becker  states  that  he  has  found  the  ratio  of  infection  in  the 
epiphyseal  Hne  to  be  1:4  of  that  of  infection  along  the  shaft.  Here, 
again,  we  have  an  illustration  of  how  a  similar  location  of  the  focus 
of  a  non-tubercular  disease  may  give  almost  identical  cUnical  signs 
with  tuberculosis.  But  a  pyogenic  infection  may  occur  along  the 
diaphj'seal  side  of  the  epiphyseal  line,  in  wliich  case,  depending  on 
the  virulence  of  the  organism,  the  cartilage  acts  more  or  less 
successfully  as  a  barrier  against  the  complete  involvement  of  the 
epiphysis  or  joint. 

It  is  generally  accepted  that  infection  of  bone  by  the  bacillus 
of  tubercle  occurs  in  the  epiphysis  in  children  with  rare  exceptions, 
and  that  these  are  either  when  the  child  is  under  an  age  in  which  a 
given  bone  has  no  ossific  centre,  or  by  direct  infection  from  a  focus 
in  the  epiphysis. 

2.  The  Roentgen  ray  shows: 

(1)  Apparent  infection  of  the  periosteum. 

(2)  Apparent  infection  of  the  marrow. 

Periosteum. — In  acute  infections  by  pyogenic  organisms  out- 
side of  the  joint-capsule  the  infection  may  start  either  with  direct 
infection  of  the  periosteum,  so  that  we  may  have  the  appearance 
of  a  definite  thickening  of  the  periosteum,  or  with  proliferation,  or 
as  a  broken  or  ragged  periosteal  outline. 

Marrow. — In  infections  of  the  marrow  we  see  in  the  Roentgen- 
ographs a  disturbance  of  the  normal  densities  of  the  bone,  and  an 
area,  or  areas,  varying  in  size  from  the  smallest  possible  point  to 
half  an  inch  or  an  inch  in  diameter.  We  find  that  the  light  easily 
penetrates  these  points,  and  we  have  then  the  so-called  "punched- 
out"  appearance,  or  area  of  increased  radiability. 

In  the  chronic  conditions  produced  by  these  pyogenic  infections 
we  see  definite  areas  of  actual  destruction  of  the  bone  with  or  with- 
out periosteal  reaction,  and  usually  with  proliferation  of  the  perios- 


218  THE  ROENTGEN  RAY  IN  PEDIATRICS. 

teum.  This  depends  to  a  certain  extent  on  the  proximity  to  the 
joint-capsule.  A  formation  of  sequestrum  may  or  may  not  take 
place.  Commonly  the  bone  is  thickened  and  the  periosteum  is 
proliferated  to  a  great  extent,  forming  an  involucrum  about  the 
shaft  with  an  area  of  rarefaction  and  with  sequestrated  pieces  of 
bone  in  the  centre  of  these  areas.  Sometimes  the  bone  becomes 
very  dense  and  only  here  and  there  by  careful  examination  can  areas 
of  rarefaction  be  detected.  Areas  of  suppuration  surround  the 
sequestrum. 

Plate  264  is  an  example  of  non-tubercular  infection  mani- 
fested in  a  child  five  years  old.  This  case  represented  a  mistake 
in  diagnosis.  There  were  classical  signs  of  tuberculosis  of  the  hip, 
and  the  diagnosis  was  tuberculosis  of  the  hip.  The  Roentgenograph 
showed  a  focus  of  disease  in  the  neck  of  the  femur,  extending  to 
the  epiphyseal  line,  but  not  into  the  epiphysis.  The  lesion  repre- 
sented a  low  grade  of  infection,  probably  non-tubercular.  Tuber- 
culosis very  seldom  comes  primarily  in  the  shaft  of  a  bone. 


PLATE  157. 

RETARDED  DEVELOPMENT  OF  HAND. 

Boy,  age  8  years.    (Life  size.) 

The  only  carpal  bones  present  arc  the  os  magnum,  unci- 
form, and  semilunar. 

A.  Points  towards  the  very  slightly  developed  lower 
epiphysis  of  the  radius. 
The  epiphyses  of  the  metacarpal  bones  and  of  the  phalanges 
are  absent. 


Plate  157 


4 


%      m 


PLATE  1;-)S. 

Age  13  years.     (Life  size.) 

.1.   Premature  o.'^sification  of  the  lower  ('i)ii)hysis  of  the  radius. 

B.  Normal  development  of  the  lower  epiphysis  of  the  ulna. 

C.  Sesamoid  bone. 

The  other  bones  arc  normal. 


PliATE  158 


PLATE   ].-,n. 

DELAYED  DEVELOP^fENT  OF  THE  SCAPHOID. 

Boy,  age  6  years.    (Life  size.) 

The  arrow  points  towards  a  verj-  slightly  developed  scaph- 
oid.   The  other  bones  of  the  foot  are  normal. 


PI.ATE  159 


l\ 


L, 


i 


% 


Pi>ATi':  Kin. 

EARLY   OSSIFTCATTOV   ol'   TIIK    VVVKH    III'II'IIYSIS   (IF  TTTF. 

IIBIA. 

(Life  size.) 

.1.   TIk'   iionual    (Icvclopiuriil   of   the   upper   cpiphy.sis   of   the 
fibula. 

B.  The  early  os-sificatioii  of  the  u])p(-r  (■i)iphysis  of  the  tihui 

wliich    has    ceased    to    develop    .synchronously    with    the 
fibula. 

C.  Early  ossifieation  of  the  lower  e])iphysis  of  the  femur. 

D.  Muscle. 

Xotc  the  clear-cut  patella  to  the  rij^ht. 


Plate  160 


PLATE   IGl. 

CELLULITIS  OF  TISSUES  OF  LEFT  ARM.  FOLLOWTXG  SUBCU- 
TAXEOUS  IXJECTIUX. 

Boy,  age  9  years,    (Reduced  Z7%.) 

A.  Infiltriitod  tissues  around  the  luuncrus. 

B.  Capitolhiin. 


Plate  161 


PLATE  102. 
HEMATOMA  OF  HEEL. 

Cliild.  age  12  years.    (Life  size.) 

A.  Infiltrated  tissues  of  the  heel. 

B.  Epiphyseal  line  of  the  os  calcis. 


Plate  1(52 


PLATE  163. 

Boy,  age  45  years.     (Reduced  3CJ%.) 
Fig.   1.    ROENTGENOGKAPH  OF  A  GlANT-CELLED  SaRCOMA  OF  THE 

Soft  Tissues  of  the  Left  Thigh. 

Fig.  2.  Photogr.\ph  of  the  Same  Subject. 

The  arrow  points  towards  the  sarcomatous  growth  in  the 
tissues  of  the  thigh. 


FIG.  1. 


Plate  1G3 


FIG.   2. 


PLAT]'.   lf)4. 
MEDULLARY  SARCOMA  OF  THE  LOWER  PART  OF  THE  FEMUR. 

Boy,  age  about  12  year-. 


Plate  1<)4 


ri.ATK   IG.-). 
PERIOSTEAL  SARCOMA— LOWER  EXD  OF  FEMUR. 

Boy.  age  10  year:?. 

Shows  marked  proliferation  of  fiic  ]K>riostoum  of  the  lower 
end  of  the  femur  with  beginning  disturbance  of  the  cortex. 


Plate  165 


PLATE  166. 
EXTREME  ATROPHY. 

Boy,  agn  13  years.      (Reduced  27%.) 

Cause  unknown. 


Plate  IGG 


PLATE   167. 
ANTERIOR  POLIOMYELITIS  OF  THE  UK  HIT  IIAXD  AXD  WRIST. 

Infant,  afc-e  18  iiioiitlis.     (lie.luced  15%.) 

1.  The  loft  normal  hand  and  wri.-^t. 

2.  Marked  absorption  of  the  lime  salts  and  consLMjucnt  incrcasi'd 

radiabilitv  in  the  riiiht  hand. 


Plate  167 


^<'i 
»( 


/m> 


-f 
// 


*? 


PLATE  168. 
ANTERIOR   POLIOMITILITIS   OF   THE    LEFT   SHOULDER. 

Boy.  age  12  mont'u-i.     (Reduced  435%.) 

The  arrow  points  towards  the  ill-developed  epiphysi.-;  of  the 
left  humeru.s,  and  shows  the  atrophy  in  size  and  quality  in 
comparison  with  the  right  arm. 


Pli^VTE  168 


PLATE   Kin. 
ANTERIOR  POLIOMYELITIS  OF  THE  LEFT  ARM 

fhiki,  age  4  years.     (Reduced  0%.) 

Decix'u.sL'd  density  of  all  the  bones. 

The  arrow  points  to  the  atrophied  muscle. 


Plate 1G9 


PLATE   170. 
SUBPERIOSTEAL  HEMORRHAGE  Ol'  TIIIC  LEFT  LEO. 

(Reiluci-d  SI",.) 

A.  Points  towards  the  organiziiif;-  clol,  tlic  darker  line  .showinji; 
uliiiost  complete  organization. 


Plate  170 


ri.ATl'.   171. 

EXOSTOSIS  OF  ASTRAGAJX'S. 
Hoy,  age  12  years. 

Tlio  arrow  points  to  the  e.vostosis. 


Plate  171 


$ 


i 


i 


PLATE   172. 
MILTIPLE  EXOSTOSES  OF  TIBIA  AND  FIBULA. 

Boy,  age  5  years.     (Reduce<l  21j%.) 

The  exostoses  arc  shown  at 

.-1.  Inner  condyle  of  femur. 

B.  Outer  part  of  fibula. 

C.  Lower  part  of  fibula. 


Pl^TE  172 


PLATE  173. 
MULTIPLE  EXOSTOSES. 

Boy,  age  5  years.    (Life  size.) 

,4.   ]*oint.s  to  exostoses  of  the  lower  part  of  the  femur. 

B.  Points  to  an  exostosis  of  the  head  of  the  fibula. 

C.  Points  to  an  exostosis  of  the  upper  part  of  the  tibia. 


Platk  173 


PLATi:  171. 

EXOSTOSIS  OF  THE  LOWEIf  I'AHT  OF  THE  I'EMUR. 

The  ari'DW  points  to  the  exostosis. 


Plate  174 


PI.ATK   17.'). 
EXOSTOSIS  OK  THE  TIBIA. 

Hoy,  age  11'  vi:ii>.     lUeducc'd  38%.) 

The  arrow  points  to  the  exostosis. 


Platp:  ITo 


rLATI'l   17(1. 
CALLUSES   ol'    I'lOirr. 

nirl,  age  10  years.     (Keduoefl  30^.)     (Same  subject  as  Plate  177  ) 

Till'  arrows  jjoiiit  toward  a  callus  of  the  scaphoiil  Ixmiv 


Platk  17(3 


PLATE  177. 
ABNORMAMA'   HICH   ARCH  OF    FOOT, 

Girl,  age  10  years.     (Retluced  31%.)     (Same  subject  as  IMate  170.) 

Arch    of    the    foot    almonnally    raised    by    the    continuous 
wearing  of  a  bad  plate. 


Plate  177 


PI.ATF.   178. 
MODERATE   FLAT-FOOT. 

Girl,  age  13  years,     (Reduced  42%.) 


Pjlate  178 


PLATK   17!). 

BACKWARD  DISPLACEMKXT  OF  THE  IXXER  COXDYLE  OF  THE 

FEMUR. 

Hoy,  age  12  year?.     (Life  size.) 

,1.  Patolla. 

B.  Displaced  condyle. 

C.  Epiphyseal  line. 


Plate  179 


.y 


PLATl':  ISO. 

FRACTURE    AND    DISPI.ACEMEXT    OF    THE    HEAD    oi'    THE 

HUMERUS. 

(Life  size.) 

.1.    Head  of  the  humerus. 
B.   Shaft  of  the  hiuuorus. 


Plate  180 


I 


PLATE  ISl. 

DISLOCATION    AND    FRAt'TURE    OF    THE    AX  ATOMIC    HEAD    OF 

THE  HUMERUS. 

Boy,  age  11  years.    (Life  size.) 

A.  Epiphyseal  lino. 


PI.ATK  181 


PLATE   182. 
FRACTURE  OF  THE  NECK  OF    I'HI':  HUMERUS. 

Boy,  age  12  years.     (Heduceil  •i%.) 

A  and  li.  Surgical  neck  of  the  humerus. 


Plate  182 


PLATE  183. 

IMPACTKI)    FRACTURE    OF    THE    SURCICAL    XECK    Ol'    THE 

HUMERUS. 

Boy,  age  4  years.    (Life  size.) 

The  arrow  points  to  the  iiiipactioii. 


Tlate  183 


PLATE   1.S4. 
DISLOCATION'  OF  THE  EPIPHYSIS  OF  THI-:   FEMUR. 

lluy,  age  5  years      'Life  size.) 

-4.  Epiphysis. 

B.  Irregular  iliaphysis. 

C.  Callus. 
0.   Patella. 


Plate  184 


/ 


P1,ATK  isr,. 

UXTRKATKD    HIT    rXITKD    CR KEN-STICK    FR.UTLKE   OF  THE 

TIBIA. 

Boy,  age  8  years.     (Reduced  33i%  ) 

.1,  />,  and  C  point  to  region  of  the  fracture. 

.1.    Thiekcning  at  tlie  point  of  the  old  fracture. 

/)'.  Thickened  cortex. 

C.  Increased  density  of  the  medullary  jiortion  of  the  .shaft. 


Pr.ATK   IS.") 


I 


I'l.ATi:    IsC). 
INTRAfAI'SULAK  FRACTLRE  OF  THE  FEMUR. 

Boy   asc  10  years.     (Life  size.) 


ri.ATE   1S(> 


PLATE  187. 
DISLOCATION   OV   THE    LOWER   EXD   OF   THE   FEMUR. 

Boy,  age  10  years.     (Life  size.) 

A.  The  condyle  dislocated  backward. 


Plate  IHT 


PLATE   18S. 

FRArTTTRE  OF  TIIK  LOWER  END  OF  THE  HUMERUS,  WITH 
INWARD  DISPLACEMENT  OF  THE  LOWER  FRAGMENT. 

Hoy,  age  10  years.     (Life  .size.) 

A.  Lower  end  of  lumicru.s. 

B.  Epiphyseal  line  of  caiiitfllum  with  hunicrus. 

C.  Epiphysis  of  tlic  olocrauon  piocess. 

D.  Epiphysis  of  radius. 

E.  CapitoUum. 

F.  Tin  splint. 


Platk  188 


PLATE   1X9. 

GREEX-STICK  I'HACTURE  OF  THE  RADIUS. 

Girl,  age  12  years.    (Reduced  7J%.) 

The  arrow  jioints  to  tlie  fracture 

The  arm  was  taken  bandaged  in  a  splint. 


PLATK   190. 

COMPLETE  FRACTURE  OF  THE  LOWER  THIRD  OF  THE  RADIUS 
AND  ULNA,  WITH  IMPACTION. 

Child,  age  3  to  4  years.    (Life  size.) 

.1 .  Impaction  of  tho  radius. 
B.   Inipaftion  of  the  ulna. 


Plate  190 


*Cl-^ 


PLATE  191. 

COMPLETE  lUACTURE  OF  THE  UAOIl.S  AM)   IL.NA. 

Age  3  years.    (Reduced  8%.) 

.1.   Frncturo  of  the  radius. 

B.  Fr.afturc  of  tlic  ulua. 

C.  Capilelluin. 


Platk  191 


PLATE  192. 

IXCOMPLETE  FRACTURE  OF  THE  LOWER  EXD  OF  THE  TIHIA. 

Infant,  age  12  months.    (Life  size.) 

A .  Fracture. 

li.  Showing  rupture  of  tlu:  luutlo  Acliillis. 


PL;ATK  192 


PLATl':  103. 

FRACTURE  OF  THE  ASTRAGALUS. 

Boy,  age  1 1  years.    (Life  size  ) 

-4  and  B  indicate  the  line  of  fracture. 


Plate  193 


PL  ATI':   1!)4. 

OLD    FRACTURE    OF    TIBIA    AXD    FIBULA,    WITH    COXNECTING 
BRIDGE   AND   FOR^L\TI()^•   OF   ABSCESS   OF  THE   AXKLE. 

^  Life  size.) 

-1.  Bridge. 

B.   Formation  of  tho  abscess  of  the  tissues  of  the  ankle. 


Plate  194 


v>^ 


PLATJ:   193. 

NORMAL  FOOT. 

Child,  age  10  years,    (lleduced  12%.) 

Shows  the  epiphysis  of  the  os  culcis  developing  from  two 
centres,  which  clinically  appeared  to  lie  a  fracture. 

The  arrow  points  to  the  two  ossific  centres  of  the  os  calcis. 


Platk  195 


X 


PLATE  196. 

FRACTURE   OF   TIBIA    WITH   COMPENSATORY   GROWTH   OF 

FIBULA. 

Girl,  age  12  years.     (Reduced  43J%.) 

-1.   Points  towards  ununited  fracture  of  the  tibia. 

B.  The  very  much  increased  cortical  bone  of  the  fibula.  Note 
the  marked  increase  in  density  of  the  whole  fibula  on 
the  left  side,  and  the  marked  decrease  of  radiability  of 
the  lower  end  of  the  femur  and  of  the  tibia  of  the  left  leg. 


Plate  11»0 


PLATE   197. 
CONGESTIOX  OF  THE  KNEE  I\  A  CASE  OF  CIIROXIC  AHTHIUTIS. 

Child,  age  fi  years.     (Life  size. 

.1.    Poiut.s  to  the  slight   capsular  thickening  ami  the  enlarged 
epiphyses  of  the  femur  and  tibia. 

B.  Points  to  the  epiphysis  of  the  fibula  which  fi'oni  irritation 

has  developed  sooner  than  on  the  right  side. 

C,  C,  C.  Remains  of  the  e])iphyseal  lines  in  an  earlier  stage  of 

development. 


Plate  197 


B' 


\ 


I 


I'LATK   19S. 
EPIPIIVSITLS  OF  THE  KN"EE-,I()I\T. 

Boy,  age  1  year.     (Life  size.) 

The  ari'ow  points  towanl.s  llu'  lUapliy.si.s  of  the  femur  which 
is  inarkedlv  irregular. 


Plate  198 


PLAT]':   199. 
EPIPHYSITIS  OF  THE  UPPER  EPIPITi'SIS  OF  THE  TIBIA. 

Girl   aRe  10  years.     (Life  .'*ize.) 

.1.    Piiints   to   the    early    ossification    of   th(>    cjiipliysis   of   the 
tibia. 
Notice  the  increased  length  of  the  fihuhi  arising  from  its 
continued  growth  after  the  growth  of  tlie  tibia  liad  been  arrested. 


Plate  199 


PLATr:  200. 

INFECTIOUS  ARTHRITIS,  ATROPHIC  TYPE. 

Girl,  age  3  years.     (Life  .size.) 

Note  the  general  osteoporosis. 

.1.   Points  towards  tlio  cortex  of  tlie  fomur  wliicli,  thoufih 

lessened  in  size,  shows  very  much  more  definitely  tlian 

a  normal  cortex  at  this  age. 
B.  Points   to   the   general    capsular    thickening.     Note   the 

irregularity  of  the  outline,  as  well  as  the  structure  of 

the  condyles  (epiphyses). 


Plate  200 


I'LATK  201. 
VILLOUS  ARTHRITIS. 

Girl,  ape  12  j-ears. 

Note  the  fieiu'i-al  ciilariiciiiriit  of  llir  coiidylos  of  the  femur, 
with  eonsideral)le  thickenuiir  of  the  tissiK^s  about  the  ktiee-joint. 


Platk  201 


\ 


PLATE  202. 
ANKYLOSIS  OF  KXEE-.IOIXT. 

Boy,  age  13  years.    (Life  size.) 

A.  Patella. 

li.  .\bnormal  arrangcmoiit  of  the  tralxM'uUv  of  the  bone. 

D.  The  bony  britlge  between  the  condyle  and  the  epiphysis  of 

the  tibia. 

E.  The  remains  of  the  e])ipliyscnl  line  in  the  ni)])cr  ])ortion  of 

the  tibia. 

F.  The  remains  of  the  epiphyseal  line  in  the  lower  end  of  the 

femur. 
Note  in  this  instance  how  the  structure  of  the  bone  is  con- 
tinuous through  the  condyles. 


Pi. ATE  202 


^ 


PLATE  203. 

INFECTIOUS  ARTHRITIS  IX  SHOULDER-JOIN'T. 

Girl,  age  8  years.    (Reduced  13i%.  i     (Same  subject  as  Plate  204  ) 

Somewhat  hypertrophicd  epiphysis  of  the  upper  extremity 
of  the  humerus,  with  atrophy  of  the  shaft  of  the  bone,  both  in 
size  and  (juality. 


Platk  203 


PLAT]':  204. 
IXFECTIOUS  ARTHRITIS  OF  HANDS. 

(Same  subject  as  Plate  203  )     (Reduced  26i%.) 

Notice  the  very  definite  inci'eased  density  of  the  eortex  of 
all  the  bones  of  both  hand.s  with  rarefaction  of  the  (•|)ii)hyses 
and  somewhat  thickened  tissue  about  the  carpus. 


Plate  204 


PLATE  205. 
INFECTIOUS  ARTHRITIS  OF  THE  HAN'D. 

Boy,  age  4i  years.     (Life  size.) 

A.  Points  to  a  perio.stcal  reaction  along  the  shaft  of  the  third 

metacarpal  bone. 

B.  Points  to  the  same  condition  in  a  less  degree  in  the  second 

metacarpal  bone. 
The  pi'oximal  portions  of  these  two  bones  show  slight  necro- 
sis and  a  considerable  thickening  of  the  tissues  in  the  region  of 
the  carpal  bones. 


Plate  205 


PLATE  206. 
EFFUSION  IX  THE  KNEE-JOINT. 

Boy,  .ige  10  years.     (Ueiluced  13i%.) 

Note  the  definite  outline  of  the  density  of  the  capsule. 


PI.ATE  200 


PLATE  207. 
ACUTE  ARTHRITIS  OF  RIGHT  HIP. 

Aga  8  months.    (Reduced  20%.  i 

The  arrow  jxiiiits  towards  the  head  of  the  fcniiu',  which 
shows  evidence  of  a  destructive  process  that  has  destroyed  the 
epiphysis  and  part  of  the  neck,  causini;  a  dislocation  of  the 
femui'.  , 

Non-tubercular  destruction  of  the  liead  of  the  hone. 


ri.ATE   207 


I'l.ATE  208. 
RHEUMATIC  FEVER— KNEE-JOINT. 

(Reduced  30%.)    (Same  subject  as  Plate  209  ) 

The  lesions  are  evident  only  in  Ihc  original  Roentgen  jjlatc. 


Plate  208 


PLATE  20n. 
RHEUMATIC  FEVER— ANKLE-JOIXT. 

(Reduced  19%.)    (Same  subject  as  Plate  208.) 

The  lesions  are  evident  only  in  the  original  Roentgen  plate. 


Plate  209 


/ 


PLATE  210. 

OSTEOMYELITIS  OF  THE  SHAFT  OF  THE  TIBIA. 

(Archiv.  Pediatrics.  July,  1907.) 

Fif/.  1.  The  Tiiua  of  a  Child  Nine  Yeaus  Old. 

The  arrow  points  towards  a  few  small  areas  of  inereased 
radlability. 

Fio.  2.  The  Same   Subject  as  Fig.  1  Three    Months  after 
First  Plate  was  Taken. 
Shows  marked    proliferation  of  the   periosteum  with  invo- 
luerum  formation  about  the  whole  shaft  of  the  til)ia. 


Plate  210 


FIG.  1  . 


FIG.    2. 


PLATE  I'll. 
CHRONIC  OSTEOMYELITIS  OF  THE  SHAFT  OF  THE  FEMUR. 

(Archiv.  Pediatrics,  July,  1907.) 

The  arrow  point.s  towanls  the  formation  of  an  involiici'uiu 
of  the  whole  shaft  of  the  femur  witli  the  foi'mation  of  a 
sequestrum. 

Note  the  extreme  osteoporosis  of  the  up])er  parts  of  the 
shaft  and  of  tlie  epiphyses  of  the  til)ia  an<l  fibula. 


Plate  211 


PLATIC  212. 

THE  RESULTS  OF  AN  ACUTE  DESTRUCTIVE  PROCESS  IN  THE 

HIPS. 

(Archiv.  Pediatrics.  July,  1907.) 

Fig.  1.  Acute  Osteomyelitis  of  the  He.\d  of  the   Femuh. 
The  arrow  points  towards  an  actual  loss  of  the  epiphysis 
and   part   of  the   neck   of   the   femur,   with   irregularity  of  the 
acetabulum  due  to  an  early  acute  non-tubercular  infection. 

Fig.  2.  Infection  of  the  Neck  of  the  Femir. 
The  arrow  points  towards  an  abscess. 


FIG.  1. 


Pt.ate  212 


^i 


PLATE  213. 

OSTEOMA'EI.ITIS  OF  THE  UPPER  SHAFT  OF  THE  TIBIA  AND  OF 
THE  EPIPHYSIS. 

(.\rchiv.  Pc(iiatric.<.  .July.  1907.) 
Boy,  Ege  8  years. 

Fig.  1.  Necrosis  with  formation  of  soqupstrum  in  the  shaft   and 
somewhat  in  the  epiphyses. 
The  arrow  points  towards  the  necrotic  area. 

Fig.  2.  The  arrow   points  to  an  area  of  actual  necrosis  within 
the  upper  shaft  of  the  tibia  as  well  as  in  the  epiphysis. 
The  very  dense  area  partly  within  the  diaphysis  and  partly 

within  the  epiphysis  is  a  plug. 


Platk  213 


FIG.   2. 


FIG.  1. 


PLATE  214. 
ACUTE  OSTEOMYELITIS  OF  THE  RIGHT  FEMUR. 

Cliild,  agt!  21  year-.     (Same  subject  as  Plate  215.) 

Shows  an  arcii  iif  iliH'ri'ascd  I'mliahility  of  the  siiLciitancous 
tissue  and  swelling  of  the  muscles  of  the  lifiht  leg.  The  outline 
of  the  bone  is  hazy.  The  eortex  is  not  so  well  ilcfined  as  normal. 
Iso  disturbance  of  the  epiphyses. 


Plate  214 


PLATE  215. 

CHROXIC   OSTEOJFi'ELITIS— (iREAT   DESTRUCTION'   OF   THE 

FEMUR. 

Age  21  yean?.    (Same  subject  a.**  Plate  214.    Taken  5  weeks  later.) 

1.  An  area  of  suppuration. 

2.  Newly  formod  ])oriostc'al  bone. 

3.  Necrotic  cortical  bone. 

The  arrows  show  points  of  attachment  of  the  capsule  and 
periosteum.  The  shaft  of  the  femur,  the  hip-  and  the  knee- 
joints  are  not  involved;  the  infection  is  confined  within  the 
limits  of  the  periosteum. 


Plati:  21.5 


PLATE  216. 
OSTEOM"V"ELITIS  OF  ELBOW. 

Boy,  age  9  years.    (Life  size.) 

Shows  considerable  dost  ruction  witli  new  foi'ination  of  bone 
witliin  tiio  joint. 

.-1.   Rarefaction  of  \hv  sliaft  of  tlac  huuu'rus. 


Pirate  210 


PI.ATi;  LM7. 
TYPHOIDAI.  OSTEOMYELITIS. 

Cbi'.d,  age  8  years.     (Reduced  58!%.) 

The  arrows  point  towards  the  humori,  wliich  show  marked 
disturbance  of  the  sliafts  due  to  necrosis  and  new  formation  of 
bone. 


Plate  217 


PLATE  218. 
OSTEOMYELITIS  OF  THE  LOWER  END  OF  THE  RADIUS. 

Boy,  aKO  fi  year."*.     (Keduneii  17%.) 

,1.   Inviilucruni   iihoiit   shaft,  with  the  hcj^hinuin  foi'iiialion  of  a 
soquestrum. 


Platk  218 


PLATl',  219. 

OSTEOMYELITIS. 

Fk;.  1.   Photogr.\i"H  of  the  .\ini. 

Bhow.s  swelling  along  the  tlor.sul  .surfat-e  of  the  forearm  and 
hand. 

Fig.  2.  Chkoxic  Osteomyelitis  of  the   Lower  Part  of  the 
Shaft  of  the  Radius,  with  Actual  Loss  of 
iVfosT  OF  the  Shaft. 
.1.    Points  to  an  ovitline  of  tliiekened  tissue. 
B.   New  formation  of  hone. 
r.   The  end  of  the  shaft. 
J>.   The  carpus. 

Fig.  3.   Poextgenograph  taken  Two  Weeks  Later. 
.1.   Points  to  an  outline  of  thickened  tissue. 

D.  The  eai'inis. 

E.  New  formation  of  hone. 


FIG.  1. 


Plate  219 


k 


FIG.   2. 


/^t 


FIG.  3. 


PLATE  220. 
OSTEOMYELITIS  OF  ACETABULIM  W nil  SEQUESTRUM. 

Child,  age  2i  yeans.     (Reduced  17%.) 

The  arrow  points  to  a  sequestrum  in  the  region  of  tiie 
acetabulum  of  the  left  hip. 

-Vhout  the  hip-joint  is  seen  an  increased  area  of  denKity 
which  is  an  abscess  within  the  capsule.  There  is  also  some 
atrojiliy  of  the  quality  of  the  epiphysis. 


Pr.ATi:  220 


PLATE  221. 
OSTEOMYELITIS  OF  FEMrU. 

C^hilil.  ajre  7  year.-.     (Reduced  12%.) 

A.  .\ica  of  density  around  the  region  of  the  cap.sule,  significant 

of  abscess  within  the  joint. 

B.  Absorption  of  the  diaphysis. 

C.  SUght  destructive  process  of  the  great  trochanter. 
E.  SUght  desti-uctive  process  of  the  great  trochanter. 

D.  Some  porosity  of  tlie  fenuir. 


Platk  221 


PLAT  I",  222. 

OSTEOMYELITIS    NEAR    THE     IIIl'-.IOIXT— PNEUMOCOCCUS 
INFECTIUX. 

Cliild,  age  34  years.     (Life  size.) 

.1.  .\n  :irc;i  of  incn'a.-^cd  nu_lial:)ilit y  chanu'ti'i'izi'd  by  alisoi])1  ion 
and  formation  of  a  sequestiann  witliin  the  sliaft  of  the 
bone. 


Plate  222 


i 


PLATI<:  223. 

0STE0.Mvi;i.rris  .\i;Aii  iiip-joixt. 

Child,  age  4§  years.     (Life  size.) 

Staphylococc'u.s  infection  of  the  neck  of  the  femur. 

A.  An  area  of  increased  radiability  due  to  a  destructive 
process  within  the  bone.  Greatly  lliiclvcned 
periosteum  of  the  iiiipcr  thii'il  of  tlic  femur. 


Plate  22.3 


PLATE  22!. 
MIXED   IXFKCTIOX  OF  IlIIMOINT— PROBABI.K   OSTKOMVKI.ITIS. 

Gir:.  aKe  ti  y<'ars.     (Reduced  32%.) 

.1.  Thickened  periosteum  within  the  cavity  of  the  pelvi.s  along 
the  iliopectineal  Hnc 

B.  Marked  absorption  of  the  neck  and  head  of  the  femur; 
rough  and  irreguhir  outhne  of  the  acetabuhim;  consid- 
erable thickening  of  tissue  about  joint;   femur  dislocated. 


Plate  224 


I 


PI.ATK  22r,. 
OSTEOMYELITIS  OF  LOWER  END  OF  TIBIA. 

Boy,  age  12  years      (Life  size.) 

A  low  grade  of  staphylococcus  infection. 

.4.  An  area  of  increased  radiability  showing  ahsorjition  and 
dostruc'tioii  of  the  tihia. 


Plate  225 


PLAT]':  L'-_>(). 
OSTEOMYELITIS  OK  THE   LOWER  EM)  OF  THE  UICHT  LEMUR. 

Boy.  age  7  years      (Kociuced  15J%.) 

The  arrows  point  to  a  process  in  the  lower  end  of  the  femur 
which  is  eharacterized,  in  the  phite,  by  a  marked  increased 
radiability  both  of  the  diaphysis  and  somewhat  of  tlie  epiphysis. 


Platk  226 


t 
t 

I 


I'LATK  227. 
OSTEOMYELITIS  OI'  THE  UPPER  EXD  OF  THE  LEFT  TUiW. 

Boy.  age  12  j'cars.     (Life  size. 

The  arrow  points  towards  a  marked  periosteal  jiroliferation 
and  an  actual  necrosis  of  bone  of  the  upper  tliird  of  the  til)ia, 
with  a  multiple  formation  of  sequestnini.  No  a])]n>rent  dis- 
turbance of  the  epiphyses. 


Platk  227 


PLATE  22.S. 

EARLY  STAGE  OF  OSTEOMYELITIS  OF  Till-:  LOWER  EXTRIAMl ■^ 

OF  THE  TIBIA. 

Hoy,  age  12  years.     (Ueduced  \2%A 

The  arrow  |K)ints  to  an  nroa  of  inprca.'^ccl  I'adiability  of  the 
lower  iliapriy.-^is  of  the  shaft  of  the  tibia. 


Platk  228 


pi.ATi':  •_'•_'!). 

OSTEOMYELITIS  or  FIBULA. 
G'.r),  age  11  years      (Life  size.) 

The  arrow  points  towards  tho  lower  third  of  the  filjula  in 
whirh  thoro  is  a  marked  periosteal  overgrowth  and  sonic  actual 
bone  necrosis. 


Pirate  229 


PLATK  •_':!(). 

UXDETERMIXED    INFECTIOX    OK    THE    LOWER    EPIPHYSIS    OF 

THE  TIHIA. 

Hoy,  age  10  years.     (Life  yize  ) 

The  arrow  points  towai'ds  an  area  of  inrroascd  radiability 
in  the  jjosterior  aspoct  of  the  fijipln'sis  of  the  til)ia. 


Plate  230 


Pr,ATK  231. 

CHRONIC    IXFKCTIOU8    OSTKO.MYELITIS    nV    Till:    ri>l'i:i;    ICN'D 

OF  THE  TIBIA. 

Boy,  age  (»  year.s.     (Life  size.) 

A.  Points  towards  a  general  Ihickeniiig  and  inrdtrat'iDn  about 

the  knee-joint. 

B.  The  area  of  actual  necrosi.s  and  di.sturhance  nf  the  hone  in 

the  .shaft  and  along  the  epiphyseal  line. 
Note  the  atrophy  in  quality  of  the  epiphyses. 


Tlatp:  231 


-*■'■»! 


I  id 


PLATE  232. 

Fig.  1.   Photogr.vph  of  the  H.\.\ds  of  .\  Boy  12  Ye.vrs  Old. 

Fk;.   2.     liOENTCK.VOGK.^PH  OF  THE  S.\.ME   H.V.NDS. 

Note  in  the  left  hand  the  marked  atrophy  of  quality  a.s 
well  as  of  size  of  all  the  bones;  considerable  rougheninj;  and 
irregularity  of  the  earinis  and  thickening  of  the  tissues. 


FIG.  1. 


Pt.atk  232 


FIG.   2. 


\ 


CHRONIC  ATROPHIC   COXDITIOX   OF   THE   KNKK-JOIXTS. 

Boy,  age  8  j-ears. 

Photoiii'iiph  of  the  siinu'  subject   ns  Plate  '2'M. 


Platk  2.r.i 


PT.ATl'.  2:51. 

AN   IXIi:(TIOUS  ARTHRITIS   OF  TIIK    KXEIC-JOIXT,  SIIOWTXc;  A 
(TiROXIC  ATROI'IIR'  COXDITIOX. 

(Some  sulijcct  as  Plate  233.)      (Life  size.) 

.4.  Points  to  marked   ]icnrill('(l   outline  of  femur  due  to  very 
dense  cortical  hone. 

B.  The    roughened    articuhir    surfaces    of    the    femur,    due    to 

some  erosion  of  the  joint  surfaces. 

C.  Points  to  the  area  of  poorly  developed  ])atella. 


Plate  234 


^-  * 


I 


X 


PLATE  235. 
SYPHILIS  OF  LOWER  EXD  OF  THE  HUMERUS. 

Boy,  age  11  years.     (Life  size.) 

.Vrrow  points  towards  marked  periosteal  overgrowth  along 
the  inner  border  of  the  humerus.  There  is  no  destruction  of 
the  bone. 


Plate  235 


PLATE  236. 
Fig.  1.  Syphilis  of  the  Eluow.     Girl,  age  2]  Years.     (Life 

SIZE.) 

.1.  Points  to  marked  periosteal  overgrowth,  with  an  area  of 
destructive  process. 

B.  Verj'  dense  new  bone-forming  periosteum. 

C.  Outline  of  the  original  bone. 

Note  that  there  is  no  actual  destruction  of  the  ulna. 

Fici.  2.  Syphilis  of  the  Forearm.     Girl,  age  41  Years. 
.1.  Points  to  marked  periosteal  reaction. 

B.  Shaft  of  ulna. 

C.  Thickening  of  tissues,  probably  due  to  abscess. 


Plate  236 


FIG.  1. 


FIG.  2. 


PLATE  237. 

SYPHILITIC  DACTYLITIS. 

Child,  age  2  years.    (Life  size.) 

Characterized  in  the  plate  by  periosteal  overgrowths,  .1,  B, 
C,  D,  with  no  apparent  disturbance  of  the  bone  itself. 


Platk  2;J7 


PLATE  23S. 
SYPHILITIC  PERIOSTITIS. 

Child,  age  5  years,    (lleduced  G%.) 

A.  Slight  thickening  of  tissues  along  crest  of  tibia. 

B.  Slight  thickening  of  the  periosteum  along  crest  of  tibia. 

C.  Slifiht  thickening  along  fil)ula. 


Plate  238 


PLATE  239. 

SVPIllLITIC   I'KRIOSTITIS  IX  SHAFT  Ol    TIIUA. 

Boy,  age  8  years.     (Reduced  23%.) 

.4.  and  11  ijoint  to  IhickciuMl  prTiostcmii. 


Platk  2.39 


PLATl':  240. 
SYPHILITIC  OSTEOPERIOSTITIS  AND  OSTEOCHOXDRITIS. 

Child,  age  6  weeks.     (Life  size.) 
[Patient  of  Dh.  L.  E.  L.\  Fetra.) 

Plate  shows  extronie  proliferative  process  alon<i  the  shafts 
of  all  the  bones  of  the  leg,  with  evident  formation  of  bone  in  the 
region  of  the  diaphyscs,  as  well  as  multiple  areas  of  necrosis. 


Plate  240 


PLATE  2tl. 
svriiii.is  OK  i.()\vi;i{  i;.\i)  ok  tiiua. 

Girl,  age  12  years.     (Reduced  6%.) 

A.  Points    to    areas   of   increased    radial^ility    due   to    marked 

absorption  of  tlic  lime  salts,  with  an  effort  towards  new 
formation  of  bone. 

B.  (\insiderable  periosteal  proliferation. 

C.  Thiekeiiing  of  the  periosteum. 


Platk  241 


B ► 


'»pi^ 


PLATE  242. 

Fig.  1.  GiKL,  Age  12  Years.    Questionable  Process  in  the 
Fourth  Metatarsal  Boxe. 
Characterized  by  marked  new  bone  formation  around  tlio 
shaft  of  the  metatarsus. 

Fig.  2.  Child,  Age  3  Years.    Tubercular  Dactylitis. 

Shows  a  distinct  area  of  destruction  of  the  bones  of  the 
middle  phahmx  of  the  middle  finger  of  tlu;  riglit  hand,  without 
any  periosteal  reaction. 

The  second  phalanx  of  the  middle  finger  of  the  left  hand 
shows  result  of  a  previous  destructive  process. 


FIG.  1. 


PI.ATK  242 


FIG.  2. 


i     • 


I 


\ 


V 


\H 


4 


V 


\ 


\ 


s*^. 


PLATls  243. 
ATROPHY  OF  KXKE  FROM  DISUSE. 

Girl,  age  12  years. 

Shows  marked  osteoporosis  of  the  left  femur  and  tibia; 
squaring  of  the  epiphyses,  witli  some  destniction  at  point  of 
arrow.    Ati'ophy  of  quality  of  the  bones. 


Plate  243 


__   L 


PLATE  244. 

TUBERCULAR  DACTYLITIS. 

Girl,  aRC  2i  years. 

The  first  phalanx  of  the  second  and  third  fingers  show 
marked  enlarsemont  of  the  shaft,  with  ro-arranjicmcnt  of  the 
structure  of  that  bone  resembling  cyst-formation. 


Plate  244 


// 


PLATE  24.-). 
TUBERCn.Ai;   DACTYLITIS. 

Cliild,  age  3  years.     (Life  size.) 

Tho  firet  and  third  metacarpal  and  the  first  phahinx  of 
tlie  foiii'th  finger  show  marked  enhirgement,  deformity,  and 
destruction  of  bone  tissue. 


PliATE  245 


V 


J 


■-V 


I'T.A'l'i:  2  1(5. 

TUBERCULOSIS  OF  TIIK  I.oWER  PART  oK  TIIK  SHAl'T  OF  THE 

ULNA. 

C'liilcl.  asf  3  years.     (Life  size.') 

Tho  arrow  jioints  toward.-^  an  area  of  ac-tual  absorption  and 
a  necrosis  of  the  hone  witli  a  small  sequestrum. 

Note  that  the  ulna  has  no  dovclopod  epiphysis. 


Platk  246 


PLATE  247. 
TUBERCULOSIS  OF  THE  CARPAL  BOXES. 

Boy,  age  5  years.    (Reduced  24%.) 

1.  The  arrow  points  towards  an  evident  necrosis  of  the  earpns 

with  considerable  thickening  of  the  tissue. 

The  inflammatory  condition  has  caused  a  more  ra\nd  dcvcl- 
oiiincnt  of  the  carpal  bones  and  the  presence  of  one  more  bone 
than  ajjpeared  in  2. 

2.  -Xornial  baud. 


Plate  247 


V 


A 


Wh 


PLATE  24S. 
TUBERCULOSIS  IN  ELBOW-JOTXT. 

Girl,  age  8  years.     (Life  size 

A.  Humerus. 

B  and  C.  Area  of  increased  radialiilily  of  the  olecranon  proc- 
ess of  the  ulna  witliin  the  joint. 
D.   Radiu.s. 


Plate  248 


PLATE  249. 
PROBAHLK  MIXED  IXFECTIOX  OF  HIP-,I()IXT. 

child,  age  5  years.     (Life  size  ) 

A.  Periosteal  proliferation  within  the  pelvis. 

B.  Marked   infiltration   and   thickening  of   ti-ssue.     The   head 

and  neck  of  the  femur  .show  a  itcneral  porosity;   beginning 
dislocation  of  the  femur. 


Plate  249 


PLAT]-:  •_>.■)(). 

TUBERCULOSIS  OF  THE  FEMUK  AND  ACETABULUM. 

Boy,  age  12  yean*.     (Life  size  ) 

This  plate  shows  the  end  result  of  a  long-standing  tuber- 
cular process  of  the  femur  and  acetabulum,  with  actual  loss 
of  the  head  and  neck  of  the  femur,  and  development  of  a  wan- 
dering acetabulum. 

A.  Acetabulum. 

B.  Remains  of  the  neck. 

C.  Great  trochaut-er. 


Plate  250 


PLATE  251. 
MIXED  INFECTIOX  OF  THE  HIP-.IOIXT  AXD  ACETABri.lM. 

Child,  age  5  years.     (Life  size.) 

.1.  Characterized  by  actual  loss  of  substance  of  the  acetabu- 
lum and  epiphysis  of  femur. 

B.  Considerable  thickening  of  the  neck  and  shaft,  with  an 
unusual  amount  of  periosteal  ijroliferation  about  the 
neck  and  shaft  of  the  bone. 


Plate  251 


PLATE  252. 
THE  EXD  RESULT  OF  AX  OLD  TUBERCULAR  PROCESS. 

Child,  age  t4  years.     (Reduced  5%.) 

A.  Diagrammatifally    represents    the    region    of    the    normal 

head  of  the  femur  and  aeetabukim.  There  has  been  an 
actual  loss  of  the  epiphysis  and  of  the  neek  of  t\w  f(Mnur 
in  this  case. 

B.  Points  to  the  greater  trochanter. 


Plate  252 


ri.ATi;  253. 
PROBABLE  TUBERCULAR   LMECTIOX  OF  THE  KPIPHYSES. 

Child,  age  8  years.     (Life  size.) 

A.  Points  to  an  area  of  bono  necrosis  of  the  epiphysis  and 

neck  of  the  femur. 

B.  Points  to  the  roughened  acetabulum. 

C.  Points  to  the  very  irreguhir  and  porous  epiphysis  of  the 

femur. 


PXiATE  253 


AN  IXFECTIorS  PROCKSS  IX  THE  XIOCK  OF  THE  FEMUR. 

Cliil.l,  age  5  years.     (Heiluced  24%.) 

The  arrow  point.s  to  an  abscess  within  tlic  left  liip-joiiit, 
with  consiclcraljlc  porosity  of  the  cpiphy.sis  of  the  fcmui-,  and 
actual  destruction  of  the  iiecl<.  Xo  atroj)hy  of  llic  shaft  of  the 
fcnuir. 

.1  and  B.  Diagrannnatically  represent  the  attachment  of 
the  capsule  of  the  riglit  liip-joint. 


PJ.ATE  -255. 

TYPICAL  TUBERCULOSIS  OF  THE  LEFT   HIP-JOIXT,  CHARACTER- 
IZED BY  MARKED  PORO.SITY  OF  THE  WHOLE  LEFT  SIDE. 

Girl,  age  8  years.    (Reduced  28%.) 

A.  Actual  loss  of  tlie  substance  of  the  hcail  of  the  femur. 

B.  Actual  loss  of  the  substance  of  the  acetabuhnn. 

C.  Extreme  atrophy  of  the  shaft  of  the  bone,  in  Ijoth  ciuality 

and  size. 


PjjATE  255 


PLATE  2.-)r). 

QUESTIOXABLE  IXrECTIUX  OF  THE  KXEE-JOIXT,  CHARACTER- 
IZED 8IMPLY  BY  AN  IXFILTRATIOX  OF  THE  TISSUES. 
PROBABLY   TUBERCULOSIS. 

Boy.  age  .5  years.     (Life  size.) 

A.  Points  to  the  infiltrated  tissues. 


Plate  25G 


PLATE  257. 

TYPICAL  TUBERCULOSIS  OF  THE  KNEE-JOINT. 

Boy,  age  8  years.     (Life -size.) 

A.  Point.s  to  increased  amount  of  fluid  and  tissue  within  tiie 

capsule. 
B  and  C.  The  irregular  developing  patella. 
D.  The  condyles,  which  show  very  irregular  formation. 


Plate  257 


PLATE  2oS. 
ABSCESS  OF  THE  THIGH. 

Boy,  age  G  years.     (Reduced  34%.) 

The  arrow  jjoints  to  an  increased  area  of  ileiisity  along  the 
anterior  aspect  of  the  thigh — jjrobably  ha'niatonia  from  trau- 
mati.sni. 


Plate  258 


PLATE  259. 
TUBERCULOSIS  OF  THE  EPIPHYSIS  OF  THE  TIBIA. 

Child,  age  9  years.     (Reduced  16%.) 

The   arrow   points   towards   an   area   of   actual   necrosis  of 
the  bone. 


PlvATK   259 


PLATE  200. 
TUBERCULOSIS  OF  THE  OS  CALCIS. 

Child,  age  2i  years.     (Reduced  10%.) 

The  lower  arrow  points  to  a  marked  necro.sis  of  the  bone 
of  the  body  of  the  os  calcis. 

The  upper  arrow  points  to  a  thickening  of  the  tissue. 


PliATE  260 


/ 


r- 


^^^ 


PLATE  •_'()!. 

TUBERCULAR  IXFECTIOX  OF  THE  lOPIPHYSIS  AST)  OF  THE 
SUPERIOR  SURFACE  OF  THE  ASTRACiALUS. 

Chikl.  age  4  years.     (Life  size.) 

A.  Abscess  within  tlie  joint  capsule. 

B.  Epiphysis  showing  necrosis  of  the  articular  surface. 

C.  The  astragalus  with  erosion  and  destruction  of  the  supe- 

rior surface. 
Note  marked  re-arrangement  of  the  bone  structure  of  the 
lower  end  of  the  tibia,  fibula,  and  tarsus;    atrophy  of  quality 
as  well  as  of  size. 


Plate  2fi1 


PLATE  262. 
TUBERCULOSIS  OF  THE  EPIPHYSIS  OF  THE  TIBIA. 

Child,  age  o  years.     (Life  .size.) 

A.  Abscess. 

B.  Erosion  of  the  epiphysis. 

C.  Points  to  the  density  of  the  tissues,  as  compared  to  that  of 

the  bone.     Bone  mar]<edly  atrophied  in  size  as  well  as 
in  quaHty. 
I).  Os  calcis. 


PT.ATE  2(>2 


PLATE  263. 

ACUTE  TUBERCULAR  IXFECTION'  OF  THE  SUPERIOR  SURFACE 
OF  THE  OS  CALCTS. 

Boy,  age  12  years.     (Life  siz3. ' 

The  arrow  ijoints  to  the  anni  of  infection. 


PI.ATE  263 


*' 


y 


I'LATI-:  2(il. 

NOX-TUBERCULAR  IXFECTIOX  ABOUT  THE  XECK  OF 
THE  FEMUR. 

Child,  age  5  years. 

The  arrow  points  towards  an  area  of  absorption  in  the  bone 
about  the  region  of  the  neck  of  the  femur.  No  atrophy  of  the 
shaft  or  of  the  epiphysis  is  noted. 


Platk  2(54 


I 


i 


INDEX 


Abdomen,  141,  142 
Abscess  of  fibula,  162 

of  humerus,  152 

mediastinal,  134 

of  OS  calcis,  214 

of  spine,  128 

of  thigh,  214 

of  tibia,  162 
Abt,  62 
Acetabulum,  necrosis,  212 

tubercular,  212 

tuberculous,  212 
Achondroplasia,  81 
Acromion  process,  epiphysis  of,  179 
Adolescence,  rhachitis  of,  112 
Anatomy,  living  normal,  illustrative  use  of,  49 
Aneurism,  131,  140 
Ankle,  chronic  atrophic,  197 

epiphysis  of,  179 

rheumatic  fever,  186 

tuberculosis  of,  215 
Ankylosis  of  knee,  168 
Anomalies  of  the  extremities,  76,  77 

or  the  head,  71 

of  the  pelvis,  SO 

of  the  ribs,  75 

of  the  spine,  71 

intra-abdominal,  76 

intra-thoracic,  76 
Arm,  atrophy  of,  154 

china  doll's,  136 

chronic  atrophic,  197 

normal  child  10  years,  45 
Arthritis,  infectious,  181 

atrophic  variety,  167 

villous,  167 
Ascites,  142 
Astragalus,  development  of,  31 

exostoses  of,  156 

fracture  of,  162 

tuberculosis  of,  215 


Atelectasis  of  lung,  133 
Athletics,  64 
Atrophy  of  arm,  154 

from  disuse,  210 

of  elbow,  155 

of  hand,  154 

infantile,  99 

of  quality  in  tuberculosis,  208 

of  shoulder,  154 

of  size  in  tuberculosis,  208 

of  wrist,  155 

Bismuth  stomach,  141 
Bone,  constituents  of,  24 
description  of,  24 
development  of,  26 
examination,  13 
structure  of,  14 
Boston  Medical  and  Surgical  Journal,  obstetri- 
cal paralysis,  91 
Boy,  9  years,  normal  hands  of,  45 
Bronchi,  131 

description  of,  133 
Broncliial  nodes,  131,  132 
description  of,  132 
tuberculosis  of,  132 
Bronchoscope,  147 
Brown,  Percy,  131,  141 
Buck  and  Bryant,  osteomalacia,  97 

Roentgen  pictures  of  osteomalacia,  98 
BuIIard,  obstetrical  paralysis,  91 

Callus  of  feet,  156 

Cardiohepatic  angle,  description  of,  23 

significance  of,  22 
Carpal  bones,  tubercular,  211 
Carpus,  development  of,  28 
Child,  five  years,  normal  foot  of,  44 
labor,  64 

laws,  65 

State  laws,  66-68 

219 


220 


INDEX. 


Child,  six  years,  knee  of,  45 

normal  thorax  of,  45 
Bhoulder  of,  45 
skeleton  of,  44 
ten  years,  normal  arm  of,  45 
normal  hand  of,  45 
pelvis  of,  45 
thorax  of,  45 
upper  legs  of,  45 
three  years,  knees  of,  44 
lower  limbs  of,  44 
Chondrodystrophia,  description  of  the  Roent- 
gen pictures,  86 
examination  by  Roentgen  method,  86 
fcetalis,  81 

cases  of,  83 
tj-pes,  82 
hyperplastica,  82 
hypoplastica,  82 
malaeica,  82 
r^sumS  of,  85 
Clavicle,  epiphysis  of,  179 
Club-hand,  78 

Coracoid  process,  epiphysis  of,  179 
Cortex,  examination,  14 

Crampton,  correlation  of  weight,  height,  and 
strength  with  scholarship,  52 
eruption    of    teeth    in    1000    elementary 

school-boys,  53 
growth  of  pubic  hair,  51 
height,  weight,  appearance  of  teeth,  and 

strength,  51 
menstrual  function,  51 
physiologic  development  correlates  closely 
with  anatomic  normal  development,  55 
Cretinism,  80 

recognition  of,  83 
Cuboid,  development  of,  31 
Cuneiform,  development  of,  29 
external,  development  of,  31 
internal,  development  of,  31 
middle,  development  of,  31 
Cyst,  tubercular,  209 

Dactylitis,  199 

syphilitic,  199,  201 

tubercular,  199,  209 
Deformities  of  jaws,  36 

of  lower  extremities,  78 


Deformities  of  upper  extremities,  77 
Dentition,  first,  temporary  teeth,  35 

second,  permanent  teeth,  35 
Development,  backward  mental,  80 
Diaphyses,  description  of,  25 
Digit,  separate,  77 
Digits,  webbed,  77 

Discrepancies  of  development  in  anatomies,  59 
Diseases  of  the  head,  115 

of  the  spine,  123 

of  nutrition,  95 
Durante,  84 

Early  years,  mental  care  of,  61 

physical  care  of,  61 
Educators,  62 
Effusion  of  knee,  185 

pericardial,  139,  140 
Elbow,  atrophy  of,  155 

epiphysis  of,  176 

infant  2-3  months,  41 

normal  child  12  years,  46 

osteomyelitis  of,  192 

poliomyelitis  of,  155 

syphilis  of,  200 
Emphysema,  137 

compensatory,  138 
Empyema,  encapsulated,  138 
Enamel,  formation  of,  33 
Epiphyseal  cartilage,  description  of,  27 

line  or  zone  of  proliferation,  examination,  15 
Epiphysis  or  epiphyses: — 

of  acromion  process,  179 

of  ankle,  179 

of  clavicle,  179 

of  coracoid  process,  179 

description  of,  25 

dislocation  of,  159 

of  elbow,  176 

examination,  15 

of  hip,  178 

of  knee,  178 

of  OS  calcis,  179 

of  pelvic  bones,  179 

of  ribs,  179 

of  scapula,  179 

of  shoulder,  176 

time  of  appearance,  26 

of  vertebrae,  179 


INDEX. 


221 


Epiphysis  of  wrist,  177 
Epiphysitis,  175 
Ethmoiditis  of  skull,  116 
Exostoses,  155 

of  astragalus,  156 

of  femur,  156 

of  fibula,  156 

of  knee,  156 

of  tibia,  156 
Exposure,  great  advantage  of  short  over  long, 

131,  141 
Extremities,  the,  149 

anomalies  of,  76,  77 

Factories,  65 

Femur,  congenital  dislocation  of,  80 

development  of,  29 

dislocation  of,  80 

early  ossification  of,  152 

exostoses  of,  156 

intercapsular  fracture,  161 

necrosis,  212 

non-tubercular  infection,  186 

osteomyeUtis  of,  190,  192 

tubercular,  212 
Fetal  rhachitis,  90 

intra-uterine,  113 
recognition  of,  83 
Fibula,  abscess  of,  162 

development  of,  30 

exostoses  of,  156 

fracture  of,  162 

osteomyelitis  of,  196 
First  permanent  molar,  calcification  of,  37 
Flat  foot,  157 
Foot,  backward  development  of,  151 

normal  child  5  years,  44 

one  toe,  79 

valgus  of,  89 
Foreign  bodies,  143 

in  intestine,  143-147 
in  larynx,  144 
in  lung,  144,  147 
in  oesophagus,  143 
Fragilitas  ossium,  87 

Gangrene,  137 

George,  Dr.,  study  of   1000  cases  of  healthy 
children,  55 


Girl,  six  months,  skeleton  of,  41 

twelve  months,  trunk  of,  42 

about  twenty-four  months,  skeleton  of,  42 
Gymnastics,  64 

Hand  or  hands: — 

atrophy  of,  154 

chronic  atrophic,  197 

infant  three  months  old,  41 

infectious  arthritis  of,  185 

irregular  development  of,  149 

normal,  child  ten  years,  45 

normal,  boy  nine  years,  45 

poliomyelitis  of,  154 
Head,  anomalies  of,  71 

diseases  of,  115 

infant  ten  weeks  old,  41 

of  normal  infant,  40 
Healthy  children,  study  of,  55 
Heart,  131 

enlarged,  139 

enlargement  of,  139 

transposition  of,  132 
Hemorrhage,  subperiosteal,  155 
Hip,  epiphysis  of,  178 

mixed  infection,  212 

osteomyelitis  of,  191,  194 

tubercular,  212,  213 
Hip-joint,  infection  of,  181 

mixed  infection,  211 
Hour-glass  contraction  of  stomach,  141 
Howship,  97 
Humerus,  abscess  of,  152 

development  of,  27 

displacement  of,  l.i9 

fracture  of,  159,  160,  161 
of  surgical  neck  of,  160 

infant  two  to  three  months,  41 

infectious  arthritis  of,  185 

osteomyelitis  of,  193 
Hydropneumothorax,  137 

Idiot,  Mongolian,  135 
Ilium,  development  of,  32 
Incisors,  central,  calcification  of,  37 

lateral,  calcification  of,  37 

permanent,  calcification  of,  37 
Index  development,  key  to,  57 
Infant,  head  of  normal,  40 


222 


INDEX. 


Infant,  head  of  ten  weeks  old,  41 
premature,  description  of,  39 
ten  days,  upper  legs  of,  40 
ten  weeks  old,  head  of,  41 

lower  extremity  of,  41 
three  and  a  half  years,  skeleton  of,  43 
three  months  old,  hand  of,  41 
two  to  three  months,  elbows  of,  41 
humeri  of,  41 
thorax  of,  41 
Infantile  atrophy,  95,  99 

differential  diagnosis  from  general  tu- 
berculosis, 100 
Infection  of  hip-joint,  181 

non-tubercular,  of  marrow,  217 
of  periosteum,  217 
Infectious  arthritis,  181 

atrophic  variety,  167 
of  hand,  185 
of  humerus,  185 
periostitis,  186 
Intestine,  congenital  malformations  of,  141 
fibrous  bands  of,  141 
nail  in,  143 
penny  in,  147 
Intra-abdominal  anomalies,  76 
Intra-thoracic  anomalies,  76 
Intra-uterine  rhachitis,  113 
Ischium,  development  of,  32 

Jaws,  deformities  of,  36 

osteomyelitis  of,  116 
Joints,  163 

atrophic,  196 

classification,  165 

hypertrophic,  196 

original  focus,  170 

Kassowitz,  rhachitis,  106' 
Kaufmann,  81 
Keriey,  62 
Knee,  ankylosis  of,  168 

child  six  years,  45 
three  years,  44 

chronic  atrophic,  197 
atrophy  of,  197 

congestion  of,  166 

effusion  of,  185 

epiphyseal  line,  166 


Knee,  epiphysis  of,  178 

suppuration  of,  167 
epiphysitis,  166 
exostoses  of,  156 
injury  to,  159 
osteochondritis,  166 
rheumatic  fever,  186 
villous  arthritis,  167 
Knee-joint,  dislocation  of  epiphysis  and  con- 
dyle, 161 
dislocation  and  fracture  of,  160 
early  tuberculosis,  213 
tuberculous,  214 
K6nig's    collection  of  infections  of  the  hip- 
joint,  181 
Kyphosis,  126 

La  Fetra,  plate  presented  by,  plate  240 
Larynx,  hook  in,  144 
Legg,  Dr.  A.  T.,  atrophy  from  disuse,  207 
Legs,  congenital  paralysis  of,  80 

chronic  atrophic,  197 

upper,  of  infant  ten  days,  40 
of  a  child  ten  years  old,  45 
Liver,  transposition  of,  132 
Lordosis,  126 
Lovett,  Dr.  R.  W.,  88      • 
Lower  extremities,  deformities  of,  78 

extremity,  delayed  development  of,  Morse's 
case,  79 
infant  ten  weeks  old,  41 

limbs,  child  three  years,  44 
Lungs,  131 

atelectasis  of,  133 

collapse  of,  134 

compression  of,  139 

doll's  china  arm  in,  145 

general  description,  133 

nail  in,  144 

Malformations  of  the  feet,  77 

of  the  hands,  77 

of  the  oesophagus,  141 

of  the  scapula,  75 

of  the  stomach,  141 

congenital,  of  the  intestines,  141 
Marrow,  non-tubercular  infections,  217 
Mediastinal  abscess,  134 
Medullary  canal,  examination,  14 


INDEX. 


223 


Mental  care  of  early  years,  61 

development,  backward,  80 
Metacarpal  bones,  development  of,  29 
Metatarsal  bones,  absent,  79 
tuberculosis  in,  209 
Metatarsus,  development  of,  31 
Molar,  first  permanent,  development  of,  37 

calcification  of,  37 
Mongolian  idiot,  135 
Morse,  patient  of,  plate  57 
Mullen's  case  of  osteogenesis  imperfecta,  85 
MuUer,  rhachitis,  106 
Muscle,  examination,  13 
Myxoedema,  80 

New-bom,  diseases  of,  69 

Nichols,  88 

Nodes,  bronchial,  132 

mesenteric,  142 
Non-tubercular  infections,  215 

of  femur,  1S6 

of  marrow,  217 

of  spine,  126 

location  of,  216 

Roentgen  ray  in,  217 
Normal  living  anatomy,  chronologic  examples 

of,  38 
Nutrition,  diseases  of,  95 

Obstetrical  paralysis,  90 
(Esophagus,  malformations  of,  141 

penny  in,  143 
Os  calcis,  abscess  of,  214 

development  of,  31 
epiphysis  of,  179 
fracture  of  epiphysis,  163 
tubercular,  214 
innominatum,  development  of,  32 
magnum,  development  of,  28 
pubis,  development  of,  32 
Osgood,  108 
Osteitis  of  spine,  126 

tubercular,  127 
Osteochondritis,  syphilis  in,  201 
Osteogenesis  imperfecta,  British  Medical  Jour- 
nal, 89 
comparison  with  osteomalacia,  98 
Lovett's  case  of,  88 
Mullen's  case  of.  85 


Osteogenesis  imperfecta,  Nichols'  case  of,  88 
recognition  of,  83 
synonyms  of,  87 
Osteomalacia,  95,  96 

comparison  with  osteogenesis  imperfecta, 98 
Osteomyelitis,  187 

of  elbow,  192 

of  femur,  190,  191,  192 

of  fibula,  196 

of  hip,  191 

of  humerus,  193 

of  jaw,  116 

of  radius,  193 

of  spine,  126,  127 

of  tibia,  189-101 
Osteoperiostitis,  syphilis  in,  201 
Osteoporosis,  82 
Osteopsathyrosis,  idiopathic,  87 
Osteosclerosis,  82 

Paralysis,  obstetrical,  90 
Parrot,  81 

Patella,  development  of,  30 
PeK'ic  bones,  epiphyses  of,  179 
Pelvis,  anomalies  of,  80 

normal  child  ten  years,  45 
Pericardium,  131,  139 

Periosteum,  acute  infections  by  pyogenic  oi^ 
ganisms,  217 

description  of,  24 

examination,  15 
Periostitis  of  spine,  126 

syphilitic,  201 
Permanent  incisors,  calcification  of,  37 

teeth,  35 
Phalanges,  development  of,  29,  31 
Physical  care  of  early  years,  61 
Pimmes,  rhachitis,  106 
Pisiform,  development  of,  29 
Pleura,  131,  137 
Pneumonia,  broncho-,  136 

lobar,  135 

unresolved,  135 
Pneumothorax,  137 
Poliomyelitis,  154 

of  elbow,  155 

of  hand,  154 

of  shoulders,  154 

of  wrist,  155 


224 


INDEX. 


Porier,  60 

Postpubescents,  height  of,  52 

scholarship  of,  52 

strength  of,  52 

weight  of,  52 
Pott's  disease,  125 
Precocious  and  bright  children,  63 
Premature  infant,  description  of,  39 
Prepubescents,  scholarship  of,  52 
Primary  areola,  27 
Pryor,  58 

Radius,  deformity  of,  78 

development  of,  28 

fracture  of,  162 

green-stick  fracture,  161 

impacted  fracture,  161 

osteomyelitis  of,  193 
Rhachitis,  95 

of  adolescence,  112 

compared  with  chondrodystrophia  foetalis, 
107 

description  of,  104 

epiphysis  and  zone  of  proliferation.  lOS 

fetal,  90 

fracture,  109 

general  structure  of  the  bone,  108 

Kassowitz,  106 

marked  deformities  of,  109 

medullary  canal,  lOS 

Muller,  106 

osseous  system,  108 

with  osteomalacia,  107 

outline  of  the  cortex  and  periosteum,  108 

Pimmes,  106 

types  of,  110 

Vierordt,  106 

Virchow,  106 

Ziegler,  106 

zone  of  proliferation,  107 
Rheumatic  fever  of  ankle,  186 

of  knee,  186 
Ribs,  anomalies  of,  75 

collapsed,  138 

epiphyses  of,  179 
Roentgen  method,  determination  of  teeth  by, 
38 
Rotch  method   of  study  of  develop- 
ment by,  56 


Roentgen  plate,  S 

ray  in  dentistry,  33 

Sacro-iliac  joint,  tubercular  process  of,  128 
Sarcoma,  medullary,  153 

myelogenous,  153 

periosteal,  154 
Scaphoid,  delayed  development,  151 

development  of,  29,  31 
Scapula,  elevation  of,  76 

epiphysis  of,  179 

malformations  of,  75 
Scoliosis,  126 
Scorbutus,  95 

hemorrhage  in,  100 

Roentgenograph  compared  with  sarcoma, 
103 
Semilunar,  development  of,  29 
Shoulder,  atrophy  of,  154 

cliild  six  years,  45 

epiphyses  of,  176 

poliomyeUtis  of,  154 
Skeleton,  cliild  about  six  years,  44 

girl  six  months,  41 

about  twenty-four  months,  42 

infant  about  three  and  a  half  years,  43 

normal  child  twelve  years,  46 
Skull,  ethmoiditis  of,  116 

fracture  of,  115 
Spina  bifida,  73 

occulta,  74 
Spine,  abscess  of,  128 

anomalies  of,  71 

diseases  of,  123 

non-tubercular  infections  of,  126 

normal  child  ten  years,  46 

osteitis  of,  126 

osteomyelitis  of,  126,  127 

periostitis  of,  126 

tuberculosis  of,  127 
Stomach,  bismuth,  141 

hour-glass  contraction,  141 

malformations  of,  141 
Stone,  157 

Stransky,  obstetrical  paralysis,  91 
Structure  of  the  bone,  examination,  14 
Stupid  children,  64 
Subcutaneous  tissue,  examination,  13 
Subperiosteal  hemorrhage,  155 


INDEX. 


225 


Supernumerary  teeth,  119 
Syphilis,  198 

of  elbow,  200 

retarded,  202 

of  tibia,  201 

of  ulna,  200 
Syphilitic  osteochondritis,  201 

osteoperiostitis,  201 

periostitis,  201 

Tarsus,  development  of,  31 
Teeth,  32 

normal  permanent,  47 

permanent,  35 

normal  development  of,  38 

supernumerary,  119 

temporary,  35 

separation  of,  36 
Thigh,  abscess  of,  214 

subperiosteal  hemorrhage  of,  155 
Thomas,  91 
Thorax,  infant,  ten  days,  40 

two  to  three  months,  41 

normal  boy  twelve  years,  46 
child,  six  years,  45 
ten  years,  45 
Tibia,  abscess  of,  162 

development  of,  30 

early  ossification  of,  152 

epiphysis,  214 

suppuration  of,  167 

exostoses  of,  156 

fracture  of,  102,  163 

green-stick  fracture,  160 

osteomyelitis  of,  1S9,  191 

early  stages  of  infection,  196 

syphilis  of,  201 

tubercular,  214 
Tissues,  atomic  weight  of,  8 

elements  of,  8 

radiability  of,  8 

subcutaneous,  examination  of,  13 
Torticollis,  75 

Trapezium,  development  of,  29 
Trapezoid,  development  of,  29 
Traumatism,  157 

technic  of,  158,  159 


Trunk,  girl  twelve  months,  42 
Tubercular  dactylitis,  199,  209,  210 
Tuberculosis,  137,  202 

of  acetabulum,  212 

acute  mihary,  136,  137 

of  ankle,  215 

of  astragalus,  215 

atrophy  in,  204,  205,  206,  207 
of  quality  in,  208 

of  bronchial  nodes,  132 

of  carpus,  211 

cyst,  209 

of  elbow,  211 

of  hip-joint,  211,  212 

of  knee,  213 

of  metatarsus,  209 

of  OS  calcis,  214,  215 

of  spine,  127 

Ulna,  deformity  of,  78 

development  of,  28 

fracture  of,  162 

impacted  fracture  of,  161 

necrosis  of,  211 

syphilis  of,  200 
Unciform,  development  of,  28 
Upper  extremities,  deformities  of,  77 

legs,  infant  ten  days,  40 

normal  child  ten  years,  45 
Urethra,  stone  in,  143 

Valgus  of  foot,  89 
Vertebrae,  epiphyses  of,  179 
Vierordt,  rhachitis,  106 
Villous  arthritis,  167 
Virchow,  rhachitis,  106 

Wolff's  law,  110,  111 
Wrist,  anomaly  of,  150 

atrophy  of,  155 

chronic  atrophic,  197 

epiphysis  of,  177 

poliomyelitis  of,  155 

Ziegler,  osteomalacia,  96 

rhachitis,  106 
Zone  of  proliferation,  description  of,  27 


15 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 


BWMED   JUN06'87 

BIOMED  LIB. 

AUG  14 1987 


58  01195  0333 


II  nil  II  111 


